Equipping for risk: Lessons learnt from the UK shale-gas experience on assessing environmental risks for the future geoenergy use of the deep subsurface

findings are presented from an investigation to improve understanding of the environmental risks associated with developing an unconventional-hydrocarbons industry in the UK. The EQUIPT4RISK project, funded by UK Research Councils, focused on investigations around Preston New Road (PNR), Fylde, Lancashire, and Kirby Misperton Site A (KMA), North Yorkshire, where operator licences to explore for shale gas by hydraulic fracturing (HF) were issued in 2016, although exploration only took place at PNR. EQUIPT4RISK considered atmospheric (greenhouse gases, air quality), water (groundwater quality) and solid-earth (seismicity) compartments to characterise and model local conditions and environmental responses to HF activities. Risk assessment was based on the source-pathway-receptor approach. Baseline monitoring of air around the two sites characterised the variability with meteorological conditions, and isotopic signatures were able to discriminate biogenic methane (cattle) from thermogenic (natural-gas) sources. Monitoring of a post-HF nitrogen-lift (well-cleaning) operation at PNR detected the release of atmospheric emissions of methane (4.2 ± 1.4 t CH4). Groundwater monitoring around KMA identified high baseline methane concentrations and detected ethane and propane at some locations. Dissolved methane was inferred from stable-isotopic evidence as overwhelmingly of biogenic origin. Groundwater-quality monitoring around PNR found no evidence of HF-induced impacts. Two approaches for modelling induced seismicity and associated seismic risk were developed using observations of seismicity and operational parameters from PNR in 2018 and 2019. Novel methodologies developed for monitoring include use of machine learning to identify fugitive atmospheric methane, Bayesian statistics to assess changes to groundwater quality, a seismicity forecasting model seeded by the HF-fluid injection rate and high-resolution monitoring of soil-gas methane. The project developed a risk-assessment framework, aligned with ISO 31000 risk-management principles, to assess the theoretical combined and cumulative environmental risks from operations over time. This demonstrated the spatial and temporal evolution of risk profiles: seismic and atmospheric impacts from the shale-gas operations are modelled to be localised and short-lived, while risk to groundwater quality is longer-term.

Risk of hospitalisation or death in households with a case of COVID-19 in England: an analysis using the HOSTED data set

Objective

To determine whether household contacts of confirmed cases of COVID-19 have an increased risk of hospitalisation or death.

Methods

We used the HOSTED data set of index cases of COVID-19 in England between June and November 2020, linked to Secondary Uses Service data on hospital episodes and Office for National Statistics’ mortality data. Multivariable logistic regression models of the odds of household contacts being hospitalised or dying within six weeks of an index case, adjusted for case type, age, sex and calendar month were calculated. Excess risk was determined by comparing the first six weeks after the index case with 6–12 weeks after the index case in a survival analysis framework.

Results

Index cases were more likely to be hospitalised or die than either secondary cases or non-cases, having adjusted for age and sex. There was an increased risk of hospitalisation for non-cases (adjusted hazard ratio (aHR) 1.10; 95% confidence interval (CI) 1.04, 1.16) and of death (aHR 1.57; 95% CI 1.14, 2.16) in the first six weeks after an index case, compared to 6–12 weeks after.

Conclusion

Risks of hospitalisation and mortality are predictably higher in cases compared to non-cases. The short-term increase in risks for non-case contacts following diagnosis of the index case may suggest incomplete case ascertainment among contacts, although this was relatively small.

Women's experiences of early pregnancy assessment unit services: a qualitative investigation

OBJECTIVE

To explore the experiences of women who had used an Early Pregnancy Assessment Unit (EPAU) service in the UK and make recommendations for their improvement.

DESIGN

Qualitative interview study.

SETTING

Early Pregnancy Assessment Units in the UK.

SAMPLE

A maximum variation sample of women who had consented to be interviewed having attended one of 26 EPAUs involved in the VESPA study in 2018.

METHODS

In-depth telephone interviews with 38 women. A thematic framework analysis was conducted, with a focus on how experiences varied according to EPAU service configuration and clinical pathway.

MAIN OUTCOME MEASURES

Women's experiences of EPAU services.

RESULTS

We found that EPAUs are highly valued, and women's experiences were generally positive. However, women reported a range of issues that negatively affected their experience. These included difficulties accessing the service, insensitive management of the investigation and treatment options of pregnancy loss, poor communication, insufficient information and a lack of support for their psychological health. These issues were not strongly associated with EPAU configuration or clinical pathway.

CONCLUSIONS

Recommendations to improve women's experiences include the separation of EPAUs from general maternity services, and we make suggestions on how to remove barriers to access by reviewing opening hours, how to provide sensitive patient management, such as automatically cancelling appointments and scans following pregnancy loss, and how to improve communication, both with women and their partners as well as with other parts of the health service.

HOSTED-England's Household Transmission Evaluation Dataset: preliminary findings from a novel passive surveillance system of COVID-19

BACKGROUND

Household transmission of SARS-CoV-2 is an important component of the community spread of the pandemic. Little is known about the factors associated with household transmission, at the level of the case, contact or household, or how these have varied over the course of the pandemic.

METHODS

The Household Transmission Evaluation Dataset (HOSTED) is a passive surveillance system linking laboratory-confirmed COVID-19 cases to individuals living in the same household in England. We explored the risk of household transmission according to: age of case and contact, sex, region, deprivation, month and household composition between April and September 2020, building a multivariate model.

RESULTS

In the period studied, on average, 5.5% of household contacts in England were diagnosed as cases. Household transmission was most common between adult cases and contacts of a similar age. There was some evidence of lower transmission rates to under-16s [adjusted odds ratios (aOR) 0.70, 95% confidence interval (CI) 0.66-0.74). There were clear regional differences, with higher rates of household transmission in the north of England and the Midlands. Less deprived areas had a lower risk of household transmission. After controlling for region, there was no effect of deprivation, but houses of multiple occupancy had lower rates of household transmission [aOR 0.74 (0.66-0.83)].

CONCLUSIONS

Children are less likely to acquire SARS-CoV-2 via household transmission, and consequently there was no difference in the risk of transmission in households with children. Households in which cases could isolate effectively, such as houses of multiple occupancy, had lower rates of household transmission. Policies to support the effective isolation of cases from their household contacts could lower the level of household transmission.

Limits on the Existence of sub-MeV Sterile Neutrinos from the Decay of ^{7}Be in Superconducting Quantum Sensors

Sterile neutrinos are natural extensions to the standard model of particle physics and provide a possible portal to the dark sector. We report a new search for the existence of sub-MeV sterile neutrinos using the decay-momentum reconstruction technique in the decay of ^{7}Be. The experiment measures the total energy of the ^{7}Li daughter atom from the electron capture decay of ^{7}Be implanted into sensitive superconducting tunnel junction (STJ) quantum sensors. This first experiment presents data from a single STJ operated at a low count rate for a net total of 28 days, and provides exclusion limits on sterile neutrinos in the mass range from 100 to 850 keV that improve upon previous work by up to an order of magnitude.

Impacts of operating conditions on efficiency of electrokinetically enhanced filtration for de-watering of orange juice and malt extract

The effects of operational factors an on an electrokinetic-enhanced filtration (EKEF) application to dewater orange juice (OJ) and malt extract (ME) was investigated. EKEF improved dewatering of both foodstuffs and resulted in net dewatering efficiencies of 7.4% and 4.9% for OJ and 10.7% and 6.3% for ME after 5.5 h processing under 30 V and 15 V, respectively. Dry matter content was increased by 19.2% and 15.6% for OJ after 5.5 h and 14.8% and 12.8% for ME after 3.5 h under 30 V and 15 V, respectively, compared with 14.9% and 10.3% under the control conditions for OJ and ME, respectively. The EKEF process effectively improved dewatering of high moisture-content foods with positive impacts on process efficiency by increased voltage, pressure, and the pore size of filters. The initial distance between electrodes had a negative impact as the distance increased. EKEF is a useful adjunct to improve high pressure filtration of foodstuffs.

Pitfalls in assessing stromal tumor infiltrating lymphocytes (sTILs) in breast cancer

Stromal tumor-infiltrating lymphocytes (sTILs) are important prognostic and predictive biomarkers in triple-negative (TNBC) and HER2-positive breast cancer. Incorporating sTILs into clinical practice necessitates reproducible assessment. Previously developed standardized scoring guidelines have been widely embraced by the clinical and research communities. We evaluated sources of variability in sTIL assessment by pathologists in three previous sTIL ring studies. We identify common challenges and evaluate impact of discrepancies on outcome estimates in early TNBC using a newly-developed prognostic tool. Discordant sTIL assessment is driven by heterogeneity in lymphocyte distribution. Additional factors include: technical slide-related issues; scoring outside the tumor boundary; tumors with minimal assessable stroma; including lymphocytes associated with other structures; and including other inflammatory cells. Small variations in sTIL assessment modestly alter risk estimation in early TNBC but have the potential to affect treatment selection if cutpoints are employed. Scoring and averaging multiple areas, as well as use of reference images, improve consistency of sTIL evaluation. Moreover, to assist in avoiding the pitfalls identified in this analysis, we developed an educational resource available at www.tilsinbreastcancer.org/pitfalls.

Application of a risk-management framework for integration of stromal tumor-infiltrating lymphocytes in clinical trials

Stromal tumor-infiltrating lymphocytes (sTILs) are a potential predictive biomarker for immunotherapy response in metastatic triple-negative breast cancer (TNBC). To incorporate sTILs into clinical trials and diagnostics, reliable assessment is essential. In this review, we propose a new concept, namely the implementation of a risk-management framework that enables the use of sTILs as a stratification factor in clinical trials. We present the design of a biomarker risk-mitigation workflow that can be applied to any biomarker incorporation in clinical trials. We demonstrate the implementation of this concept using sTILs as an integral biomarker in a single-center phase II immunotherapy trial for metastatic TNBC (TONIC trial, NCT02499367), using this workflow to mitigate risks of suboptimal inclusion of sTILs in this specific trial. In this review, we demonstrate that a web-based scoring platform can mitigate potential risk factors when including sTILs in clinical trials, and we argue that this framework can be applied for any future biomarker-driven clinical trial setting.

Molecular detection of Streptococcus equi subspecies equi in face flies (Musca autumnalis) collected during a strangles outbreak on a Thoroughbred farm

The objective of this study was to detect Streptococcus equi subspecies equi (S. equi) (Lactobacillales: Streptococcaceae) using quantitative polymerase chain reaction (qPCR) in flies collected from a farm with a documented outbreak of strangles. A total of 1856 face flies [Musca autumnalis (Diptera: Muscidae)] were collected using conventional fly traps. The flies were processed for nucleic acid purification and tested for the presence of S. equi by qPCR. A total of 10/1856 flies (0.54%) tested qPCR-positive for S. equi. The results may implicate the presence of face flies as a risk factor for the transmission of S. equi and highlight the need to institute proper husbandry measures, biosecurity protocols and fly control in order to reduce the potential for infection in at-risk horses.

On the Stability of Reported Pregnancy Intentions from Pregnancy to 1 Year Postnatally: Impact of Choice of Measure, Timing of Assessment, Women's Characteristics and Outcome of Pregnancy

OBJECTIVES

Retrospective, cross-sectional estimates of pregnancy intention, as used in the Demographic Health Survey (DHS), are the global norm. The London Measure of Unplanned Pregnancy (LMUP) is a newer, psychometrically validated measure which may be more reliable. This paper assesses the reliability of the LMUP and the DHS question over the first postnatal year and explores the effects of maternal characteristics or pregnancy outcome on reported pregnancy intention.

METHODS

We compared the test-retest reliability of the LMUP (using the AC coefficient) and DHS question (using the weighted Kappa) over the first postnatal year using data from Malawian women. We investigated the effect of maternal characteristics and pregnancy outcome using t-tests, Chi squared or Fisher's exact tests, and calculated odds ratios to estimate effect size.

RESULTS

The DHS question was associated with a statistically significant decrease in the prevalence of unplanned pregnancies from 1-to-12 months postnatally; the LMUP was not. The LMUP had moderate to substantial reliability (0.51-0.66); the DHS had moderate reliability (0.56-0.58). The LMUP's stability was not related to any of the factors examined; the stability of the DHS varied by marital status (p = 0.033), number of children (p = 0.048) and postnatal depression (p < 0.001). Both underestimated unintended pregnancy postnatally vis-à-vis the LMUP in pregnancy.

CONCLUSIONS FOR PRACTICE

The LMUP is a more reliable measure of pregnancy intention than the DHS in the first postnatal year and does not vary by maternal characteristics or pregnancy outcome. The LMUP should become the gold-standard for measuring pregnancy intention and should be collected in pregnancy or at the first postnatal opportunity.

IQN path ASBL report from the first European cfDNA consensus meeting: expert opinion on the minimal requirements for clinical ctDNA testing

Liquid biopsy testing is a new laboratory-based method that detects tumour mutations in circulating free DNA (cfDNA) derived from minimally invasive blood sampling techniques. Recognising the significance for clinical testing, in 2017, IQN Path provided external quality assessment for liquid biopsy testing. Representatives of those participating laboratories were invited to attend a workshop to discuss the findings and how to achieve quality implementation of cfDNA testing in the clinical setting, the discussion and outcomes of this consensus meeting are described below. Predictive molecular profiling using tumour tissue in order to select cancer patients eligible for targeted therapy is now routine in diagnostic pathology. If insufficient tumour tissue material is available, in some circumstances, recent European Medicines Agency (EMA) guidance recommends mutation testing with plasma cfDNA. Clinical applications of cfDNA include treatment selection based on clinically relevant mutations derived from pre-treatment samples and the detection of resistant mutations upon progression of the disease. In order to identify tumour-related mutations in amongst other nucleic acid material found in plasma samples, highly sensitive laboratory methods are needed. In the workshop, we discussed the variable approaches taken with regard to cfDNA extraction methods, the tests, and considered the impact of false-negative test results. We explored the lack of standardisation of complex testing procedures ranging from plasma collection, transport, processing and storage, cfDNA extraction, and mutation analysis, to interpretation and reporting of results. We will also address the current status of clinical validation and clinical utility, and its use in current diagnosis. This workshop revealed a need for guidelines on with standardised procedures for clinical cfDNA testing and reporting, and a requirement for cfDNA-based external quality assessment programs.

A framework for the development of effective anti-metastatic agents

Most cancer-related deaths are a result of metastasis, and thus the importance of this process as a target of therapy cannot be understated. By asking 'how can we effectively treat cancer?', we do not capture the complexity of a disease encompassing >200 different cancer types - many consisting of multiple subtypes - with considerable intratumoural heterogeneity, which can result in variable responses to a specific therapy. Moreover, we have much less information on the pathophysiological characteristics of metastases than is available for the primary tumour. Most disseminated tumour cells that arrive in distant tissues, surrounded by unfamiliar cells and a foreign microenvironment, are likely to die; however, those that survive can generate metastatic tumours with a markedly different biology from that of the primary tumour. To treat metastasis effectively, we must inhibit fundamental metastatic processes and develop specific preclinical and clinical strategies that do not rely on primary tumour responses. To address this crucial issue, Cancer Research UK and Cancer Therapeutics CRC Australia formed a Metastasis Working Group with representatives from not-for-profit, academic, government, industry and regulatory bodies in order to develop recommendations on how to tackle the challenges associated with treating (micro)metastatic disease. Herein, we describe the challenges identified as well as the proposed approaches for discovering and developing anticancer agents designed specifically to prevent or delay the metastatic outgrowth of cancer.

Results of the UK NEQAS for Molecular Genetics reference sample analysis

Aims

In addition to providing external quality assessment (EQA) schemes, United Kingdom National External Quality Assessment service (UK NEQAS) for Molecular Genetics also supports the education of laboratories. As an enhancement to the Molecular Pathology EQA scheme, a human cell-line reference sample, manufactured by Thermo Fisher Scientific (AcroMetrix), was provided for analysis. This contained many variants, present at frequencies between 1% and 17.9%.

Methods

One hundred and one laboratories submitted results, with a total of 2889 test results on 53 genes being reported. Known polymorphisms, 46/2889 (1.59%) results, were excluded. Variants detected in the seven most commonly reported (and clinically relevant) genes, KRAS, NRAS, BRAF, EGFR, PIK3CA, KIT and PDGFRA, are reported here, as these genes fall within the scope of UK NEQAS EQA schemes.

Results

Next generation sequencing (NGS) was the most commonly performed testing platform. There were between 5 and 27 validated variants in the seven genes reported here. Eight laboratories correctly reported all five NRAS variants, and two correctly reported all eight BRAF variants. The validated mean variant frequency was lower than that determined by participating laboratories, with single-gene testing methodologies showing less variation in estimated frequencies than NGS platforms. Laboratories were more likely to correctly identify clinically relevant variants.

Conclusions

Over 100 laboratories took the opportunity to test the ‘educational reference sample’, showing a willingness to further validate their testing platforms. While it was encouraging to see that the most widely reported variants were those which should be included in routine testing panels, reporting of variants was potentially open to interpretation, thus clarity is still required on whether laboratories selectively reported variants, by either clinical relevance or variant frequency.

A longitudinal study on the acceptance and effects of a therapeutic renal food in pet dogs with IRIS-Stage 1 chronic kidney disease

Currently, nutritional management is recommended when serum creatinine (Cr) exceeds 1.4 mg/dl in dogs with IRIS-Stage 2 chronic kidney disease (CKD) to slow progressive loss of kidney function, reduce clinical and biochemical consequences of CKD, and maintain adequate nutrition. It is unknown if dietary interventions benefit non-azotemic dogs at earlier stages. A prospective 12-month feeding trial was performed in client-owned dogs with IRIS-Stage 1 CKD (n = 36; 20 had persistently dilute urine with urine specific gravity (USG) <1.020 without identifiable non-renal cause; six had persistent proteinuria of renal origin with urine protein creatinine (UPC) ratio >0.5; 10 had both). Ease of transition to therapeutic renal food and effects on renal biomarkers and quality of life attributes were assessed. Dogs were transitioned over 1 week from grocery-branded foods to renal food. At 0, 3, 6, 9, and 12-months a questionnaire to assess owner's perception of their pet's acceptance of renal food and quality of life was completed. Renal biomarkers, including serum Cr, blood urea nitrogen (BUN), and symmetric dimethylarginine (SDMA), and USG and UPC ratio were measured. Of 36 dogs initially enrolled, 35 (97%) dogs were transitioned to therapeutic renal food. Dogs moderately or extremely liked the food 88% of the time, ate most or all of the food 84% of the time, and were moderately or extremely enthusiastic while eating 76% of the time. All renal biomarkers (Cr, BUN, and SDMA) were decreased (p ≤ .05) from baseline at 3-months, and remained decreased from baseline at 12-months in dogs completing the study (n = 20). Proteinuria was reduced in 12 of 16 dogs (p = .045) with proteinuria. Owners reported improvement in overall health and quality of life attributes, and hair and coat quality (all p < .01). In summary, dogs with IRIS-Stage 1 CKD readily transition to renal food. Decreasing serum biomarker concentrations and reduction in proteinuria suggest stabilized kidney function.

Integration of next-generation sequencing in clinical diagnostic molecular pathology laboratories for analysis of solid tumours; an expert opinion on behalf of IQN Path ASBL

The clinical demand for mutation detection within multiple genes from a single tumour sample requires molecular diagnostic laboratories to develop rapid, high-throughput, highly sensitive, accurate and parallel testing within tight budget constraints. To meet this demand, many laboratories employ next-generation sequencing (NGS) based on small amplicons. Building on existing publications and general guidance for the clinical use of NGS and learnings from germline testing, the following guidelines establish consensus standards for somatic diagnostic testing, specifically for identifying and reporting mutations in solid tumours. These guidelines cover the testing strategy, implementation of testing within clinical service, sample requirements, data analysis and reporting of results. In conjunction with appropriate staff training and international standards for laboratory testing, these consensus standards for the use of NGS in molecular pathology of solid tumours will assist laboratories in implementing NGS in clinical services.

Rumen Microorganisms Decrease Bioavailability of Inorganic Selenium Supplements

Despite the availability of selenium (Se)-enriched trace mineral supplements, we have observed low Se status in cattle and sheep offered traditional inorganic Se supplements. Reasons for this may include inadequate intake or low bioavailability of inorganic Se sources. The objective of this study was to determine whether rumen microorganisms (RMO) alter the bioavailability of Se sources commonly used in Se supplements. Rumen microorganisms were isolated from ewes (n = 4) and incubated ex vivo with no Se (control), with inorganic Na selenite or Na selenate, or with organic selenomethionine (SeMet). Total Se incorporated into RMO and the amount of elemental Se formed were determined under equivalent conditions. Incorporation of Se from Na selenite, Na selenate, or SeMet into RMO was measured as fold change compared with control (no added Se). Incorporation of Se into microbial mass was greater for SeMet (13.2-fold greater than no-Se control) compared with inorganic Se supplements (P = 0.02); no differences were observed between inorganic Na selenate (3.3-fold greater than no-Se control) and Na selenite (3.5-fold greater than no-Se control; P = 0.97). Formation of non-bioavailable, elemental Se was less for RMO incubated with SeMet compared with inorganic Se sources (P = 0.01); no differences were observed between Na selenate and Na selenite (P = 0.09). The clinical importance of these results is that the oral bioavailability of organic SeMet should be greater compared with inorganic Se sources because of greater RMO incorporation of Se and decreased formation of elemental Se by RMO.

Serum Concentrations of Symmetric Dimethylarginine and Creatinine in Dogs with Naturally Occurring Chronic Kidney Disease

Background

Serum concentrations of symmetric dimethylarginine (SDMA) detected chronic kidney disease (CKD) in cats an average of 17.0 months before serum creatinine (Cr) concentrations increased above the reference interval.

Objectives

To report on the utility of measuring serum SDMA concentrations in dogs for detection of CKD before diagnosis by measurement of serum Cr.

Animals

CKD dogs (n = 19) included those persistently azotemic for ≥3 months (n = 5), dogs that were azotemic at the time of death (n = 4), and nonazotemic dogs (n = 10). CKD dogs were compared with healthy control dogs (n = 20).

Methods

Retrospective study, whereby serum Cr concentrations were determined by enzymatic colorimetry and serum SDMA concentrations were determined by liquid chromatography‐mass spectrometry in dogs with necropsy confirmed CKD.

Results

Serum SDMA increased before serum Cr in 17 of 19 dogs (mean, 9.8 months; range, 2.2–27.0 months). Duration of elevations in serum SDMA concentrations before the dog developed azotemia (N = 1) or before the dog died (N = 1) was not determined. Serum SDMA and Cr concentrations were linearly related (r = 0.84; P < .001). Serum SDMA (r = −0.80) and serum Cr (r = −0.89) concentrations were significantly related to glomerular filtration rate (both P < .001).

Conclusion and Clinical Importance

Using serum SDMA as a biomarker for CKD allows earlier detection of kidney dysfunction in dogs than does measurement of serum Cr. Earlier detection might be desirable for initiating renoprotective interventions that slow progression of kidney disease.

Nutritional Interventions that Slow the Age-Associated Decline in Renal Function in a Canine Geriatric Model for Elderly Humans

OBJECTIVE

To determine the effects of feeding traditional and renal protective foods (RPF) supplemented with functional food bioactives on glomerular filtration rate (GFR), lean body percent (LB%), and selected circulating biomarker and metabolite concentrations in a geriatric dog model.

DESIGN

Randomized block design and cross-sectional study.

SETTING

Hill's Pet Nutrition, Inc. dog colony.

PARTICIPANTS

Eighty-one geriatric dogs (mean age, 10.4; range, 7.9-14.2 years) and 30 mature-adult dogs (mean age, 5.0; range, 3.3-6.9 years).

INTERVENTION

Geriatric dogs were fed one of three foods (n = 27 per group) for 6 months: a traditional RPF (control) that was energy dense and mildly protein-restricted, or control food supplemented with increasing amounts of functional food bioactives: fish oil, lipoic acid, fruits and vegetables, and higher quality protein sources [functional foods one (FF1) and two (FF2)]. Geriatric dogs were compared before and after the feeding trial with mature adult dogs.

MEASUREMENTS

Renal function was assessed by GFR, LB% was determined by dual energy x-ray absorptiometry, and circulating biomarkers and metabolites were measured in blood.

RESULTS

Before the feeding trial, GFR (+28.2%), LB% (+18.6%), and serum total protein (+10.0%) were higher in mature versus healthy geriatric dogs (all P<0.001). Geriatric dogs consuming all three foods increased (P<0.001) GFR over time; group averages ranged from 13.0-16.9%. Dogs fed the highest supplemented level of bioactives (FF2) had lower (P<0.001) symmetric dimethylarginine (SDMA) concentrations (-14.3%). Feeding functional foods did not alter body weight, but increased (P<0.001) serum protein concentration (+6.7%).

CONCLUSION

Supplementation with functional food bioactives can temporarily reverse the age-associated decline in renal function and serum total protein.

Optimizing sharing of hospital biobank samples

Implementing technical guidelines and standards as well as ways to boost cooperation should facilitate sharing of hospital biobank samples.

Improving recorded volume in mesial temporal lobe by optimizing stereotactic intracranial electrode implantation planning

PURPOSE

Intracranial electrodes are sometimes implanted in patients with refractory epilepsy to identify epileptic foci and propagation. Maximal recording of EEG activity from regions suspected of seizure generation is paramount. However, the location of individual contacts cannot be considered with current manual planning approaches. We propose and validate a procedure for optimizing intracranial electrode implantation planning that maximizes the recording volume, while constraining trajectories to safe paths.

METHODS

Retrospective data from 20 patients with epilepsy that had electrodes implanted in the mesial temporal lobes were studied. Clinical imaging data (CT/A and T1w MRI) were automatically segmented to obtain targets and structures to avoid. These data were used as input to the optimization procedure. Each electrode was modeled to assess risk, while individual contacts were modeled to estimate their recording capability. Ordered lists of trajectories per target were obtained. Global optimization generated the best set of electrodes. The procedure was integrated into a neuronavigation system.

RESULTS

Trajectories planned automatically covered statistically significant larger target volumes than manual plans [Formula: see text]. Median volume coverage was [Formula: see text] for automatic plans versus [Formula: see text] for manual plans. Furthermore, automatic plans remained at statistically significant safer distance to vessels [Formula: see text] and sulci [Formula: see text]. Surgeon's scores of the optimized electrode sets indicated that 95% of the automatic trajectories would be likely considered for use in a clinical setting.

CONCLUSIONS

This study suggests that automatic electrode planning for epilepsy provides safe trajectories and increases the amount of information obtained from the intracranial investigation.

Comparison of serum concentrations of symmetric dimethylarginine and creatinine as kidney function biomarkers in cats with chronic kidney disease

Background

Symmetric dimethylarginine (SDMA) has been shown to be an accurate and precise biomarker for calculating estimated glomerular filtration rate (GFR) in humans, as well as a more sensitive biomarker than serum creatinine concentration (sCr) for assessing renal dysfunction.

Objectives

The purpose of this retrospective study was to report on the utility of measuring serum SDMA concentrations in cats for detection of chronic kidney disease (CKD) before diagnosis by conventional measurement of sCr.

Animals

Chronic kidney disease cats (n = 21) included those persistently azotemic for ≥3 months (n = 15), nonazotemic cats with GFR >30% decreased from median GFR of normal cats (n = 4), and nonazotemic cats with calcium oxalate kidney stones (n = 2). Healthy geriatric cats (n = 21) were selected from the same colony.

Methods

Symmetric dimethylarginine concentrations (liquid chromatography‐mass spectroscopy) and sCr (enzymatic colorimetry) were determined retrospectively from historical data or banked serum samples in azotemic cats or at the time GFR (iohexol clearance) was measured in nonazotemic cats.

Results

Serum SDMA (r = −0.79) and sCr (r = −0.77) concentrations were significantly correlated to GFR (both P < .0001). Symmetric dimethylarginine became increased before sCr in 17/21 cats (mean, 17.0 months; range, 1.5–48 months). Serum SDMA had higher sensitivity (100%) compared with sCr (17%), but lower specificity (91% versus 100%) and positive predictive value (86% versus 100%).

Conclusion and Clinical Importance

Using serum SDMA as a biomarker for CKD allows earlier detection of CKD in cats compared with sCr, which may be desirable for initiating renoprotective interventions that slow progression of CKD.

Relative seed and fruit toxicity of the Australian cycads Macrozamia miquelii and Cycas ophiolitica: further evidence for a megafaunal seed dispersal syndrome in cycads, and its possible antiquity

An apparent contradiction in the ecology of cycad plants is that their seeds are known to be highly poisonous, and yet they seem well adapted for seed dispersal by animals, as shown by their visually conspicuous seed cones and large seeds presented within a brightly colored fleshy "fruit" of sarcotesta. We tested if this sarcotesta could function as a reward for cycad seed dispersal fauna, by establishing if the toxic compound cycasin, known from the seeds, is absent from the sarcotesta. The Australian cycads Macrozamia miquelii and Cycas ophiolitica were tested (N = 10 individuals per species) using gas chromatography / mass spectrometry. Cycasin was detected at 0.34 % (fresh weight) in seed endosperm of M. miquelii and 0.28 % (fresh weight) in seed endosperm of C. ophiolitica. Cycasin was absent from the sarcotesta of the same propagules (none detected in the case of M. miquelii, and trace quantities detected in sarcotesta of only four of the ten C. ophiolitica propagules). This laboratory finding was supported by field observations of native animals eating the sarcotesta of these cycads but discarding the toxic seed intact. These results suggest cycads are adapted for dispersal fauna capable of swallowing the large, heavy propagules whole, digesting the non-toxic sarcotesta flesh internally, and then voiding the toxic seed intact. Megafauna species such as extant emus or cassowaries, or extinct Pleistocene megafauna such as Genyornis, are plausible candidates for such dispersal. Cycads are an ancient lineage, and the possible antiquity of their megafaunal seed dispersal adaptations are discussed.

Effect of transport on blood selenium and glutathione status in feeder lambs

Stress from transport may be linked to increased generation of reactive oxygen species, the removal of which requires reduced glutathione and selenium. The aim of this experiment was to examine the effect of transport on glutathione and Se status of feeder lambs. Recently weaned lambs (n = 40) were blocked by gender and BW on d 0 of the experiment and randomly assigned to 2 treatment groups: group 1, no transport and full access to feed and water (control), and group 2, 8-h road transport followed by another 16 h of feed deprivation (transport). After 24 h, both treatment groups were treated the same. All lambs were weighed, and blood samples were collected at 0, 8, 24, and 72 h and analyzed for whole-blood (WB) and serum Se concentrations, serum NEFA concentrations, and erythrocyte concentrations of glutathione. Transport of feeder lambs for 8 h followed by another 16 h of feed deprivation transiently (significant at 24 h but no longer different at 72 h) decreased BW and erythrocyte glutathione concentrations and increased serum NEFA and blood Se concentrations compared with control lambs. Our results suggest that 8 h of transport followed by another 16 h of feed deprivation results in fatty acid and Se mobilization from tissue stores with a coincident decrease in erythrocyte glutathione concentrations.

Adaptation of innate lymphoid cells to a micronutrient deficiency promotes type 2 barrier immunity

How the immune system adapts to malnutrition to sustain immunity at barrier surfaces, such as the intestine, remains unclear. Vitamin A deficiency is one of the most common micronutrient deficiencies and is associated with profound defects in adaptive immunity. Here, we found that type 3 innate lymphoid cells (ILC3s) are severely diminished in vitamin A-deficient settings, which results in compromised immunity to acute bacterial infection. However, vitamin A deprivation paradoxically resulted in dramatic expansion of interleukin-13 (IL-13)-producing ILC2s and resistance to nematode infection in mice, which revealed that ILCs are primary sensors of dietary stress. Further, these data indicate that, during malnutrition, a switch to innate type 2 immunity may represent a powerful adaptation of the immune system to promote host survival in the face of ongoing barrier challenges.

Influence of contact size on the detection of HFOs in human intracerebral EEG recordings

OBJECTIVE

High frequency oscillations (HFOs) are brief electroencephalographic events associated with epileptic activity, and likely representing biological markers of the epileptogenic zone. HFOs are usually detected with intracranial EEG and detection is influenced by contact size. The size of commercially available intracerebral electrodes varies widely. This study assesses HFO detection rates from adjacent electrode contacts in human intracerebral recordings.

METHODS

Intracerebral recordings were collected from 11 patients undergoing stereoelectroencephalographic investigation using hybrid depth electrodes containing adjacent large (0.8 or 5 mm(2)) and small (0.2 or 0.3 mm(2)) contacts. HFOs were marked manually during 5-min tracings in 131 pairs of adjacent large and small contacts. HFO rates per minute and mean event durations were compared between adjacent contacts.

RESULTS

A minimal but statistically significant advantage in ripple detection was found in a subgroup of large contacts. Otherwise, HFO rates and mean event durations were not statistically different between groups.

CONCLUSION

The size of clinical contacts within the studied range did not influence HFO detection in a clinically relevant manner. Larger contacts provide a minimal advantage for ripple detection.

SIGNIFICANCE

Our findings suggest that commercially available intracerebral electrodes with contacts between 0.2 and 5 mm(2) likely possess similar HFO detection abilities.

Fit for the future? The place of global health in the UK's postgraduate medical training: a review

OBJECTIVES

That health is now global is increasingly accepted. However, a 'mismatch between present professional competencies and the requirements of an increasingly interdependent world' has been identified. Postgraduate training should take account of the increasingly global nature of health; this paper examines the extent to which they currently do.

DESIGN

Trainees across 11 medical specialties reviewed the content of their postgraduate curriculum.

SETTING

Not relevant. PARTCIPANTS: None.

MAIN OUTCOME MEASURES

Competencies were coded as 'UK' (statement only relevant to UK work), 'global' (statement with an explicit reference to aspects of health outside the UK) or generic (relevant both to the UK and international settings).

RESULTS

Six of the 11 curricula reviewed contained global health competencies. These covered the global burden or determinants of disease and appropriate policy responses. Only one College required trainees to 'be aware of the World Health Organization', or 'know the local, national and international structures for health care'. These cross-cutting competencies have applicability to all specialties. All 11 curricula contained generic competencies where a global health perspective and/or experience could be advantageous, e.g. caring for migrant or culturally different patients.

CONCLUSION

Trainees in all specialties should achieve a minimum requirement of global health awareness. This can be achieved through a small number of common competencies that are consistent across core curricula. These should lead on from equivalent undergraduate competencies. Addressing the current gap in the global health content of postgraduate medical curricula will ensure that the UK has health professionals that are trained to meet the health challenges of the future.

Organic and inorganic selenium: IV. passive transfer of immunoglobulin from ewe to lamb

Newborn lambs depend on their dams for passive transfer of immunoglobulins, primarily IgG, for protection from harmful pathogens until their own immunological defenses have developed. Previous studies have suggested that supplementation with Se results in a modest increase in IgG concentration in serum of newborn calves and lambs. To evaluate the effect of the Se source and supplementation rate in ewes during pregnancy on passive transfer of IgG to their lambs, 210 Polypay, Suffolk, or Suffolk × Polypay cross ewes were divided into 7 treatment groups (n = 30 each) and drenched weekly with no Se, at the maximum FDA-allowed concentration with inorganic Na-selenite or organic Se-yeast (4.9 mg Se/wk), or with inorganic Na-selenite and organic Se-yeast at supranutritional concentrations (14.7 and 24.5 mg Se/wk). Ewe serum IgG concentrations were measured within 30 d of parturition, ewe colostrum and lamb serum IgG concentrations were measured at parturition before suckling, and lamb serum IgG concentrations were measured again at 48 h postnatal. Ewes receiving 24.5 mg Se/wk tended to have or had, independent of Se source, greater colostral IgG concentrations than ewes receiving 4.9 mg Se/wk overall (81.3 vs. 66.2 mg/mL; P = 0.08) and for Polypay ewes only (90.1 vs. 60.7 mg/mL; P = 0.03). Polypay ewes receiving Se-yeast at 24.5 mg Se/wk transferred a greater calculated total IgG amount to their lambs than Polypay ewes receiving Se-yeast at 4.9 mg Se/wk (15.5 vs. 11.6 g; P = 0.02), whereas the converse was true (interaction between Se source and dose concentration; P = 0.03) for Polypay ewes receiving inorganic Na-selenite at 24.5 mg Se/wk vs. Na-selenite at 4.9 mg/wk (11.6 vs. 15.7 g; P = 0.08). Our results suggest that supranutritional Se supplementation of Polypay ewes during pregnancy increases colostral IgG concentrations but that the optimal supplementation rate for IgG transfer from ewe to lamb may differ for Na-selenite and Se-yeast.

Organic and inorganic selenium: III. Ewe and progeny performance

Selenium is an essential micronutrient in sheep, and deficiency can limit lamb growth and survival. To evaluate how different chemical forms of Se administered to mature ewes at comparative dosages affect ewe and progeny performance, 240 ewes were divided into 8 treatment groups (n = 30 each) and drenched weekly with no Se; at the maximum FDA-allowed concentration with inorganic Na-selenite or organic Se-yeast (4.9 mg Se/wk); with inorganic Na-selenate (8.95 mg Se/wk); or with inorganic Na-selenite and organic Se-yeast at supranutritional concentrations (14.7 and 24.5 mg Se/wk, respectively). The treatment period started approximately 2 wk before breeding and lasted for 62.5 wk. Ewes of the no-Se and Se-yeast groups continued treatments for another 21 to 24 wk through a second lambing season. Chemical form or dosage of Se did not affect ewe reproductive performance based on proportion of ewes lambing in each treatment group, or number of lambs born, nursed, or weaned per ewe (all P > 0.10). Ewes receiving the highest supplementation rate of Se-yeast at 24.5 mg Se/wk had higher BCS (scale 1 to 5) at the end of yr 1 (2.95 vs. 2.66; P = 0.05) than ewes receiving Se-yeast at 4.9 mg Se/wk. Performance was better in lambs from ewes receiving Se-yeast at 24.5 mg Se/wk than in lambs from ewes receiving Se-yeast at 4.9 mg Se/wk or no Se. In yr 1, lambs from ewes receiving Se-yeast at 24.5 vs. 4.9 mg Se/wk were heavier at 120 d of age (37.0 vs. 34.2 kg; P = 0.05). In yr 2, lambs from ewes receiving Se-yeast at 24.5 mg Se/wk were or tended to be heavier at 60 d of age than lambs from ewes receiving no Se (21.2 vs. 19.0 kg; P = 0.04) or lambs from ewes receiving Se-yeast at 4.9 mg Se/wk (19.2 kg; P = 0.09). This effect was more pronounced in ewes raising multiple lambs. We conclude that supranutritional supplementation of ewes with Se-yeast at 24.5 mg Se/wk improves lamb growth and ewe health without negatively affecting reproductive performance.

Paradigm changes in health lead to paradigm changes in pathology

For the sake of safety and quality of care as well as efficiency of care processes, health systems undergo a paradigm change towards personalized, ubiquitous, health services. This change includes preventive and predictive medicine based on advanced translational medicine. Here we introduce domain-specific, organizational, and technical paradigms, requirements and solutions for personalized, ubiquitous, care. Emphasizing the formal aspects of modeling and implementing Telehealth and personal health (pHealth) interoperability and the entailed multidisciplinary integration, and illustrate the drivers behind and benefits of personalized medicine with a specific focus on the changing trends and impact on pathology, especially emphasizing Telepathology.

Organic and inorganic selenium: I. Oral bioavailability in ewes

Although the essentiality of dietary Se for sheep has been known for decades, the chemical source and Se dosage for optimal health remain unclear. In the United States, the Food and Drug Administration (FDA) regulates Se supplementation, regardless of the source of Se, at 0.3 mg of Se/kg of diet (as fed), which is equivalent to 0.7 mg of Se/d or 4.9 mg of Se/wk per sheep. The objectives of this study were to evaluate the effects of Se source (inorganic vs. organic) and supplementation rate (FDA vs. supranutritional rates of 14.7 and 24.5 mg of Se/wk) on whole-blood (WB) and serum-Se concentrations. Mature ewes (n = 240) were randomly assigned to 8 treatment groups (n = 30 each) based on Se supplementation rate (4.9, 14.7, and 24.5 mg of Se•wk(-1)•sheep(-1)) and source [Na-selenite, Na-selenate (4.9 mg/wk only), and organic Se-yeast] with a no-Se control group (0 mg of Se/wk). Treatment groups were balanced for healthy and footrot-affected ewes. For 1 yr, ewes were individually dosed once weekly with 0, 4.9, 14.7, or 24.5 mg of Se, quantities equivalent to their summed daily supplementation rates. Serum- and WB-Se concentrations were measured every 3 mo in all ewes; additionally, WB-Se concentrations were measured once monthly in one-half of the ewes receiving 0 or 4.9 mg of Se/wk. Ewes receiving no Se showed a 78.8 and 58.8% decrease (P < 0.001) in WB- (250 to 53 ng/mL) and serum- (97 to 40 ng/mL) Se concentrations, respectively, over the duration of the study. Whole-blood Se decreased primarily during pregnancy (-57%; 258 to 111 ng/mL) and again during peak lactation (-44%; 109 to 61 ng/mL; P < 0.001). At 4.9 mg of Se/wk, Se-yeast (364 ng/mL, final Se concentration) was more effective than Na-selenite (269 ng/mL) at increasing WB-Se concentrations (P < 0.001). Supranutritional Se-yeast dosages increased WB-Se concentrations in a dose-dependent manner (563 ng/mL, 14.7 mg of Se/wk; 748 ng/mL, 24.5 mg of Se/wk; P < 0.001), whereas WB-Se concentrations were not different for the Na-selenite groups (350 ng/mL, 14.7 mg of Se/wk; 363 ng/mL, 24.5 mg of Se/wk) or the 4.9 mg of Se/wk Se-yeast group (364 ng/mL). In summary, the dose range whereby Se supplementation increased blood Se concentrations was more limited for inorganic Na-selenite than for organic Se-yeast. The smallest rate (FDA-recommended quantity) of organic Se supplementation was equally effective as supranutritional rates of Na-selenite supplementation in increasing WB-Se concentrations, demonstrating the greater oral bioavailability of organic Se.

Co-adjuvant effects of retinoic acid and IL-15 induce inflammatory immunity to dietary antigens

Under physiological conditions the gut-associated lymphoid tissues not only prevent the induction of a local inflammatory immune response, but also induce systemic tolerance to fed antigens. A notable exception is coeliac disease, where genetically susceptible individuals expressing human leukocyte antigen (HLA) HLA-DQ2 or HLA-DQ8 molecules develop inflammatory T-cell and antibody responses against dietary gluten, a protein present in wheat. The mechanisms underlying this dysregulated mucosal immune response to a soluble antigen have not been identified. Retinoic acid, a metabolite of vitamin A, has been shown to have a critical role in the induction of intestinal regulatory responses. Here we find in mice that in conjunction with IL-15, a cytokine greatly upregulated in the gut of coeliac disease patients, retinoic acid rapidly activates dendritic cells to induce JNK (also known as MAPK8) phosphorylation and release the proinflammatory cytokines IL-12p70 and IL-23. As a result, in a stressed intestinal environment, retinoic acid acted as an adjuvant that promoted rather than prevented inflammatory cellular and humoral responses to fed antigen. Altogether, these findings reveal an unexpected role for retinoic acid and IL-15 in the abrogation of tolerance to dietary antigens.

Genome-wide identification of direct target genes implicates estrogen-related receptor alpha as a determinant of breast cancer heterogeneity

Estrogen-related receptor alpha (ERRalpha) is an orphan nuclear receptor, the expression of which correlates with negative prognosis in breast cancer. ERRalpha shares functional features with the estrogen receptor alpha (ERalpha) and its activity is modulated by the ERBB2 signaling pathway. Using genome-wide binding sites location analyses in ERalpha-positive and ERalpha-negative breast cancer cell lines, we show that ERRalpha and ERalpha display strict binding site specificity and maintain independent mechanisms of transcriptional activation. Nonetheless, ERRalpha and ERalpha coregulate a small subset of common target genes via binding either to a dual-specificity binding site or to distinct cognate binding sites located within the extended promoter region of the gene. Although ERRalpha signaling in breast cancer cells is mostly independent of ERalpha, the small fraction of common ERRalpha/ERalpha targets comprises genes with high relevance to breast tumor biology, including genes located within the ERBB2 amplicon and GATA3. Finally, unsupervised hierarchical clustering based on the expression profiling of ERRalpha direct target genes in human breast tumors revealed four main clusters that recapitulate established tumor subtypes. Taken together, the identification and functional characterization of the ERRalpha transcriptional network implicate ERRalpha signaling as a determinant of breast cancer heterogeneity.

The use of atropine for facilitation of direct current cardioversion from atrial fibrillation--results of a pilot study

BACKGROUND

The importance of the role of the autonomic nervous system (ANS) in the initiation and propagation of atrial fibrillation has been demonstrated in the condition of paroxysmal atrial fibrillation. However, the role of the ANS in patients with chronic atrial fibrillation is less clear. Some patients with chronic atrial fibrillation are resistant to the standard techniques of direct current (DC) cardioversion.

HYPOTHESIS

We sought to investigate whether excessive vagal tone might prevent the restoration of sinus rhythm and to establish that the abolition of vagal tone using intravenous atropine will facilitate DC cardioversion in patients with atrial fibrillation who are resistant to the standard cardioversion techniques.

METHODS

Beginning in August 1994, a change in the protocol for elective DC cardioversion of atrial fibrillation was made to include the use of intravenous atropine for patients resistant to the standard techniques of DC cardioversion.

RESULTS

Over a 2-year period, 140 elective cardioversions were performed for atrial fibrillation. Sinus rhythm could not be restored on 31 occasions. Intravenous atropine prior to a further 360 J shock with paddles in the anteroposterior position allowed sinus rhythm to be restored on nine occasions. Patients with successful cardioversion after atropine had significantly better left ventricular function than those who remained in atrial fibrillation (p = 0.001) as well as a tendency toward a smaller left atrium.

CONCLUSION

This study suggests that high vagal tone, which is dominant in patients with structurally normal hearts, may prevent the termination of atrial fibrillation by standard techniques of DC cardioversion, and that the abolition of high vagal tone by atropine facilitates the restoration of sinus rhythm.

Effect of parenteral selenium administration to sheep on prevalence and recovery from footrot

BACKGROUND

Insufficient intake of selenium (Se) is common in many regions, and can contribute to increased susceptibility to and prolonged recovery from infectious diseases.

OBJECTIVE

To determine the effect of Se administration in decreasing the severity and prevalence of footrot in sheep.

ANIMALS

Thirty-eight footrot-affected and 19 nonaffected sheep from a commercial flock of known high incidence of footrot.

METHODS

Placebo-controlled, prospective, 15-month clinical trial. Footrot-affected sheep were randomly assigned into 2 groups (n = 19) and injected with either 5 mg Se (footrot [FR]-Se) or saline (FR-Sal) at 1-month intervals for the duration of the study. Unaffected sheep (controls) received no treatment. Sheep feet were examined, trimmed, and scored for footrot with a scale of 0 (no footrot) to 4 (extensive) at 0, 3, 6, 9, and 15 months. Sheep were also bled at time 0 and then at 3, 6, and 15 months to assess whole blood Se concentrations.

RESULTS

At time 0, control sheep (255 +/- 11 ng/mL) had higher (P < .05) whole blood Se concentrations compared with FR-Se (205 +/- 12 ng/mL) and FR-Sal (211 +/- 14 ng/mL) sheep. By 6 months, FR-Se sheep (317 +/- 9 ng/mL) had whole blood Se concentrations greater (P < .05) than both control (281 +/- 14 ng/mL) and FR-Sal (277 +/- 16 ng/mL) sheep. FR-Se ewes showed a faster decline in highest lesion score at 3 (P= .012) and 6 (P= .0036) months, and a greater decrease in the number of feet with foot score >0 at 6 (P= .020) months compared with FR-Sal ewes. Sheep with blood Se concentrations <300 ng/mL were at 3.5 times greater risk (1.1-12.1 confidence interval, odds ratio) for FR, although this relationship was only significant (P= .04) at 6 months of the study.

CONCLUSIONS AND CLINICAL IMPORTANCE

In sheep with footrot, improved Se status in conjunction with routine control practices result in more rapid improvement of foot lesions.

DNA perseverance of microorganisms exposed to silica: an experimental study

The persistence of DNA from microorganisms exposed to various concentrations of SiO2 (ranging from 0 to 3000 p.p.m.) was monitored over time. The impact of silica mineralization or silicification on the longevity of 16S rRNA and 16 s rDNA genes from whole cells of Bacillus subtilis and Escherichia coli K12 was quantified using real-time polymerase chain reaction (RT-PCR), and cells were visualized using optical microscopy. For B. subtilis, DNA longevity decreased in experiments with higher levels of SiO2 (1000 and 3000 p.p.m.), in comparison to zero or low (100 p.p.m.) levels. For B. subtilis, cell viability was greatest in the absence of silica, and markedly decreased in the presence of any concentration of silica. Survival of Escherichia coli cells, on the other hand, was not sensitive to silica in the solution. All cells died at similar rates over the 180 days they were monitored, decreasing to about 1% survival. DNA longevity for E. coli did appear to be enhanced to some degree by the presence of 1000 p.p.m. silica, but higher or lower concentrations showed no increased longevity in comparison to the no-silica control. Overall, findings of this study do not support the hypothesis that siliceous environments provide enhanced protection and preservation of DNA over time. However, results of this study do provide guidelines on the persistence of DNA that might be expected in modern silica-rich environments, which may be an important factor for proper characterization of present-day microbial communities.

Simultaneous presentation of coronary heart disease in identical twins

The development of coronary artery disease involves a complex interplay between environmental and genetic factors, with premature coronary artery disease having a strong genetic component. We present the case a pair of monozygotic identical twins presenting near simultaneously with coronary artery disease and identical atherosclerotic lesions despite significant differences in environmental risk factors and being divided geographically by 12,000 miles. This is of enormous importance and not merely curiosity value as it will have implications for the prevention of coronary artery disease, provide an opportunity for the development of new therapeutic strategies, and aid targeted primary prevention through family screening.

Drug facilitated sexual assault--a review

This review was undertaken to identify the evolutionary process in the current understanding of allegations of drug facilitated sexual assault (DFSA), so that those who work in this field may gain a better understanding of the complexities involved in such cases. Several definitions of DFSA are provided as well as a list of intoxicating substances which have so far been incriminated in this crime. Perception and alcohol use is addressed, whilst an examination of intoxication and victim outcomes reveals disturbing but important information which needs to be centrally placed within health education campaigns with a degree of urgency. The review identifies the effects of alcohol on sexual behaviour, drinking patterns and specific quantitative research indicating very high alcohol levels in some instances. In practical terms, suggestions are made following Operation Matisse, to address prevention, early detection and easier identification of DFSA cases so that victims' needs are prioritised and appropriately addressed.

Lymphocyte blastogenic response to ovalbumin in a model for canine allergy

Lymphocyte stimulation tests (LST) were performed in five dogs sensitised with ovalbumin (OVA) and seven healthy dogs. In addition, all five OVA-sensitised and two control dogs were tested after two in vivo provocations with OVA-containing eye drops. The isolated cells were suspended in culture media containing OVA and were cultured for up to 12 days. Proliferation was measured as reduction in 5,6-carboxylfluorescein diacetate succinimidyl ester (CFSE) intensity by flow cytometry on days 0, 3, 6, 9 and 12. A cell proliferation index (CPI) for each day and the area under the curve (AUC) of the CPI was calculated for each dog. All OVA-sensitised dogs demonstrated increased erythema after conjunctival OVA application. The presence of OVA-specific lymphocytes was demonstrated in 2/5 OVA-sensitised dogs before and 4/5 after in vivo provocation. Using the AUC, the difference between OVA-sensitised and control dogs was significant in all three LST before in vivo provocation (P<0.05) and borderline significant (P=0.053) in 2/3 LST after provocation. The most significant difference in CPI was observed after 9 days of culture (P=0.001). This pilot study indicates that the LST allows detection of rare antigen specific memory T-cells in dogs previously sensitised to, but not concurrently undergoing challenge by a specific antigen.

External validation of established risk adjustment models for procedural complications after percutaneous coronary intervention

BACKGROUND

Workable risk models for patients undergoing percutaneous coronary intervention (PCI) are needed urgently.

OBJECTIVE

To validate two proposed risk adjustment models (Mayo Clinic Risk Score (MC), USA and North West Quality Improvement Programme (NWQIP), UK models) for in-hospital PCI complications on an independent dataset of relatively high risk patients undergoing PCI.

SETTING

Tertiary centre in northern England.

METHODS

Between September 2002 and August 2006, 5034 consecutive PCI procedures (validation set) were performed on a patient group characterised by a high incidence of acute myocardial infarction (MI; 16.1%) and cardiogenic shock (1.7%). Two external models-the NWQIP model and the MC model-were externally validated.

MAIN OUTCOME MEASURE

Major adverse cardiovascular and cerebrovascular events: in-hospital mortality, Q-wave MI, emergency coronary artery bypass grafting and cerebrovascular accidents.

RESULTS

An overall in-hospital complication rate of 2% was observed. Multivariate regression analysis identified risk factors for in-hospital complications that were similar to the risk factors identified by the two external models. When fitted to the dataset, both external models had an area under the receiver operating characteristic curve >or=0.85 (c index (95% CI), NWQIP 0.86 (0.82 to 0.9); MC 0.87(0.84 to 0.9)), indicating overall excellent model discrimination and calibration (Hosmer-Lemeshow test, p>0.05). The NWQIP model was accurate in predicting in-hospital complications in different patient subgroups.

CONCLUSIONS

Both models were externally validated. Both predictive models yield comparable results that provide excellent model discrimination and calibration when applied to patient groups in a different geographic population other than that in which the original model was developed.

An exploration into study design for biomarker identification: issues and recommendations

Genomic profiling produces large amounts of data and a challenge remains in identifying relevant biological processes associated with clinical outcome. Many candidate biomarkers have been identified but few have been successfully validated and make an impact clinically. This review focuses on some of the study design issues encountered in data mining for biomarker identification with illustrations of how study design may influence the final results. This includes issues of clinical endpoint use and selection, power, statistical, biological and clinical significance. We give particular attention to study design for the application of supervised clustering methods for identification of gene networks associated with clinical outcome and provide recommendations for future work to increase the success of identification of clinically relevant biomarkers.

Maternal dietary n-3 fatty acids alter immune cell fatty acid composition and leukotriene production in growing chicks

The effect of feeding different amounts of n-6 and n-3 fatty acids (FA) to hens on immune tissue FA composition and leukotriene production of hatched chicks was investigated. Hens were fed diets supplemented with either 3.0% sunflower oil (Diet I), 1.5% sunflower+1.5% fish oil (Diet II), or 3.0% fish oil (Diet III) for 46 days. The hatched chicks were fed a diet containing C18:3n-3, but devoid of longer chain n-6 and n-3 FA, for 21 days. Spleen docosahexaenoic acid (DHA) content was higher in chicks from hens fed Diet III (P<0.05). The bursa content of arachidonic acid was lower in chicks hatched from hens fed Diet III (P<0.05), and the ratio of n-6 to n-3 FA was significantly higher in bursa of chicks hatched to hens fed Diet I (P<0.05). Eicosapentaenoic acid (EPA) and DHA contents were higher in bursa of chicks hatched from hens fed Diet III (P<0.05). Thrombocytes from chicks hatched to hens fed Diet III produced the most leukotriene B(5) (LTB(5)). The ratio of LTB(5) to LTB(4) concentrations was also highest (P<0.05) in chicks hatched to hens fed Diet III. These results indicate that modulating maternal dietary n-6 and n-3 FA may alter leukotriene production in chicks, which could lead to less inflammatory-related disorders in poultry.