Comparing Effectiveness of a Generic Oral Nutritional Supplement With Specialized Formula in the Treatment of Active Pediatric Crohn's Disease

BACKGROUND

Exclusive enteral nutrition (EEN) is the recommended induction treatment of mild to moderate active pediatric Crohn's disease (CD). This study compared outcomes of 2 proprietary polymeric formulas. Treatment effectiveness was examined along with practical aspects of formula delivery and differences in estimated treatment costs.

METHODS

Data were retrospectively collected from patients with CD who received a generic oral nutritional supplement (Fortisip) across 2 centers (RCH, Melbourne and RHSC, Edinburgh). This was compared with a prospective cohort (RHC, Glasgow) that used a specialized formula (Modulen IBD). The data collected included patient demographics, remission rates, biochemical markers, administration method, and anthropometrics. The estimated treatment cost was performed by comparing price per kcal between each formula.

RESULTS

One hundred seventy-one patients were included (106 Fortisip, 65 Modulen IBD, 70 female; median age 13.3 yrs). No difference was demonstrated in remission rate (Fortisip n = 67 of 106 [63%] vs Modulen IBD n = 41 of 64 [64%], P = .89), nonadherence rate (Fortisip n = 7 of 106 [7%] vs Modulen IBD 3 of 64 [5%], P = .57) or method of administration (NGT Fortisip use n = 16 of 106 [12%] vs Modulen IBD 14 of 65 [22%]; P = .31). There was no difference in reduction of biochemical disease markers between the groups (C-reactive protein , P = .13; erythrocyte sedimentation rate, P = .49; fecal calprotectin, P = .94). However, there was a cost-saving of around £500/patient/course if the generic oral nutritional supplement was used.

CONCLUSIONS

The generic oral nutritional supplement and specialized formulas both had similar clinical effectiveness in induction of remission in pediatric CD. However, there is considerable cost-saving when using a generic oral nutritional supplement.

Gateways not gatekeepers – reaching seldom-heard groups to gather public health community insights

Background

Each local authority in England must develop a Health and Wellbeing Strategy (HWS) in collaboration with NHS partners to plan and support delivery of local improvements in health and wellbeing. HWSs often draw on diverse sources but few are informed by consultative exercises involving citizens. South Tyneside Council in Northern England sought to ensure their new HWS was community-informed, specifically including seldom-heard groups and individuals. Specific objectives of this community insights research were to:

1.Target sampling and recruitment activities at typically marginalized, vulnerable or otherwise underrepresented groups

2.Explore the health and wellbeing-related views and priorities of these groups to address health inequalities

Methods

A mapping exercise was undertaken to identify organisations who might act as gatekeepers to accessing participants from underrepresented groups. Focus groups were held in settings-based venues where members would be comfortable and known to one another. Representatives of voluntary and community sector (VCS) organisations often helped to co-facilitate the discussions.

Results

119 participants took part in 16 group discussions. Three were held online, two were outdoors, while 11 involved community venues where the groups regularly met. We reached older and younger people, minority ethnic groups, and vulnerable men and women, including residents who had experienced homelessness, mental health issues, substance misuse, offending, domestic violence and learning disabilities. Participants were largely concerned with the wider determinants of health (such as poverty, employment, and leisure spaces), shifting the narrative away from individual lifestyle factors that tend to be the focus of much public health discourse.

Conclusions

Gatekeepers from the VCS were essentially gateways, enabling us to include underrepresented voices in local consultation processes and generate new insights to inform the South Tyneside HWS.

Key messages

Accuracy of Point-of-Care-Ultrasonography in Confirming Shoulder Reduction in Emergency Departments

Aims Accurate identification of the successful reduction of a dislocated shoulder could avoid additional episodes of procedural sedation and repeated performance of X-rays. The objective of this study was to assess the diagnostic accuracy of point-of-care-ultrasound (POCUS) in the confirmation of a successful joint reduction in patients with shoulder dislocation. Methods This was a single-centre, prospective observational study set in an urban academic ED in Ireland, with a convenience sample of adult patients with shoulder dislocation on X-ray. Ultrasound was performed on participants before and after joint reduction using a posterior approach technique. The operator's confidence levels were recorded after image acquisition. Results Thirty-three subjects were recruited. All dislocations were correctly identified on pre-reduction US, indicating a sensitivity of 100% (CI 89.42 - 100). Post-reduction US confirmed successful reduction in 30 subjects that were subsequently reported as such on X-Ray, giving it a specificity of 100% (CI 88.43 - 100). Failure to achieve reduction was correctly identified on US in three cases, resulting in post-reduction US Sensitivity of 100% (CI 29.24 - 100) and 100% accuracy (CI 89.42 - 100). Conclusion This study has shown that POCUS, with a posterior approach technique, has 100% sensitivity and specificity in confirming successful shoulder reduction in the ED.

Design and assessment of a penile fracture simulation model

OBJECTIVE

To design and assess a novel penile fracture simulation model for teaching penile fracture repair.

METHODS

We used a validated circumcision simulator to create a model. Foreskin for a circumcision was divided into two halves. A transverse slit ("simulated fracture") was created on one part of the first half of the foreskin (mimicking "tunica") and was applied over the penile model. A red jelly tablet ("clot") was placed underneath the cut. A second full-length of foreskin was applied over it to cover the defect. The model was assessed by participants and expert faculty at the Urology Simulation Boot Camp. Evaluation was performed using a 5-point Likert Scale questionnaire. Data was analysed using Microsoft Excel and IBM SPSS Statistics V25. The intra-class correlation was calculated using a "One-way random model".

RESULTS

Twenty-two urology trainees and four experts participated in the evaluation. The majority of trainees strongly agreed (59%, n=13) the model is useful for training with experts similarly agreeing in 75% of cases. The appearance of penile fracture was considered good by both trainees (68%, n=14) and faculty (75%). Overall, the ability of the model to represent a realistic simulation of the task was considered excellent by 23% of participants and good by 64%. Personal confidence after simulation in managing a similar situation was considered high among trainees. The main difficulties reported were related to fascial planes and urethra.

CONCLUSION

This is the first simulation model for penile fracture repair and has demonstrated face validity at a national urology bootcamp.

A training model to teach early management of priapism

BACKGROUND

Ischaemic priapism is a urological emergency with early treatment required to prevent irreversible loss of erectile function. Corporal aspiration is the first step in management. Currently, there are no satisfactory training models to develop skills in a controlled environment. We have therefore developed a novel training model to teach trainees the steps of penile aspiration in a safe and representative way.

MATERIALS AND METHODS

We have developed a priapism model using an old catheterisation teaching model. Face validity of the model was assessed by participants and experienced urologists teaching on a urology boot camp. All had managed at least 5 cases of actual priapism. Responses were reported using a 5-point Likert Scale. Data were analysed using IBM SPSS Statistics V25. The intra-class correlation was calculated using a «One-way Random model».

RESULTS

Eleven urologists and seven trainees participated in the evaluation. The model appearance was reported as the best simulation trait of the priapism model. Tactile feedback from needle insertion for aspiration was also felt to be realistic with 72.6% reporting it as «Good» or «very good» and 85.7% reported the model to be realistic for needle insertion. Intra-class correlation amongst experts was 0.552. Majority of trainees (83.3%) reported a realistic simulation. All evaluators agreed or strongly agreed that the model provided a good simulated experience that would be useful in training.

CONCLUSION

Our model provides a realistic simulation of corporal aspiration. It can be used repeatedly. Overall, the proposed model appears to be a promising tool for training junior doctors in the initial management of ischaemic priapism.

Optimal Timing of CT Scanning in the Rapid Access Lung Cancer Clinic

Aims To investigate whether a ‘CT first’ approach to Rapid Access Lung Cancer Clinic (RALC) review could be feasible in an Irish context. Methods A retrospective review of our institution’s Lung Cancer Database was performed. All RALC first attendances from 2012-2018 were identified. Timing of CT was assessed as well as CT imaging findings. Results Total first attendances in this period were 2372, of whom 91% had CT thorax as part of their evaluation. 866 patients (37%) were diagnosed with lung cancer, all had an abnormal CT. 1290 patients (54%) underwent CT but did not have lung cancer after clinical work up. 34% of patients diagnosed with Lung Cancer had their CT scan post RALC. Time to diagnosis was longer in those who had post RALC CT (34.5 versus 21 days) Conclusion CT scanning plays a vital role in the RALC pathway. Initial delays in obtaining CT can result in delayed time to diagnosis. These findings warrant close consideration when devising future national lung cancer policy.

Effects of larvae density and food concentration on Crown-of-Thorns seastar (Acanthaster cf. solaris) development in an automated flow-through system

Coral-eating Crown-of-Thorns Sea stars (Acanthaster spp.) are major contributors to coral reef loss in the Indo-Pacific region. A release from food limitation of their planktotrophic larvae through enhanced pelagic productivity is one of the main hypothesis explaining population outbreaks (‘nutrient limitation hypothesis’). To improve the understanding of these outbreaks we developed an automated flow- through larvae rearing system that maintained food (microalgae) at set levels over the course of four 15d experiments. This resulted in stable food concentrations in experimental tanks. Increased algae concentrations had a significant positive effect on larval development and size at 10 and 15 days post fertilization (dpf). Larvae densities had no effect at 10 dpf. At 15 dpf greater larvae densities were associated with declines in larvae size. Larval development was slowed under higher larvae densities. Thus, the effects of algae concentration and larvae density were additive at 15 dpf, with larvae under low densities at a given algae concentration being further developed than those under higher densities. The development of a flow-through system gives greater insight into the effect of algae and larvae concentrations on Acanthaster development, and the system can be applied to further test the nutrient-limitation hypothesis for present and future outbreaks.

Superior immunogenicity of HCV envelope glycoproteins when adjuvanted with cyclic-di-AMP, a STING activator or archaeosomes

Three decades after the discovery, hepatitis C virus (HCV) is still the leading cause of liver transplantation and poses a major threat to global health. In spite of recent advances in the development of direct acting antivirals, there is still a need for a prophylactic vaccine to limit the virus spread and protect at-risk populations, especially in developing countries, where the cost of the new treatments may severely limit access. The use of recombinant HCV glycoproteins E1E2 (rE1E2) in combination with the MF59, an oil-in-water emulsion-based adjuvant, has previously been shown to reduce the rate of chronicity in chimpanzees and to induce production of cross-neutralizing antibodies and cellular immune responses in human volunteers. To further improve neutralizing antibody responses in recipients along with robust T cell responses, we have explored the immunogenicity of different adjuvants when formulated with the HCV rE1E2 vaccine in mice. Our data show that cyclic di-adenosine monophosphate (c-di-AMP) and archaeosomes elicit strong neutralizing antibodies similar to those elicited using aluminum hydroxide/monophosphoryl lipid A (Alum/monophos. /MPLA) and MF59. However, both c-di-AMP and archaeosomes induced a more robust cellular immune response, which was confirmed by the detection of vaccine-specific poly-functional CD4⁺ T cells. We conclude that these adjuvants may substantially boost the immunogenicity of our E1E2 vaccine. In addition, our data also indicates that use of a partial or exclusive intranasal immunization regimen may also be feasible using c-di-AMP as adjuvant.

Regional movement patterns of a small-bodied shark revealed by stable-isotope analysis

This study used stable-isotope analysis to define the nearshore regional residency and movements of the small-bodied Australian sharpnose shark Rhizoprionodon taylori. Plasma and muscle δ(13) C and δ(15) N of R. taylori were collected from across five embayments and compared with values of seagrass and plankton from each bay. Linear distances between adjacent bays ranged from 30 to 150 km. There was a positive geographic correlation between R. taylori tissue and environmental δ(13) C values. Populations with the highest tissue δ(15) N were collected from bays that had the highest environmental δ(15) N values. These results suggest that R. taylori did not forage more than 100 km away from their capture location within 6 months to 1 year. The successful application of isotope analysis to define R. taylori movement demonstrates that this technique may be used in addition to traditional methods to study the movement of sharks, even within similar habitats across regionally small spatial scales (<100 km).

Abstract 61: A mouse model for small round cell tumors induced by the Ewing sarcoma oncogene EWS/FLI1

Ewing Sarcoma is a malignant bone tumor in children and young adults. Upon current multimodal therapy only ∼60% of patients are long term survivors. Due to the rarity of the disease, however, only few novel agents can be tested in clinical trials. An animal model closely recapitulating the human disease would be highly needed to more rapidly explore new therapies. Ewing sarcoma is driven by the EWS/FLI1 (EF) chimeric oncogene, an aberrant Ets transcription factor that is toxic to many cell types, but tolerated by mesenchymal stem cells (MSC). Ewing sarcoma is postulated to develop from mesenchymal progenitor cells (MPC), but transgenic approaches tolerating EF expression lack behind. EF expression was shown to induce a differentiation block in MSC but does not drive full transformation. Thus, it was hypothesized that cooperating mutations are required for sarcomagenesis. We challenged this concept in a conditional mouse model in which EWS/FLI1 is activated early during endochondral bone formation by a Prx1-driven Cre recombinase (EFPrx1). EFPrx1 mice follows Mendelian ratio, but newborns suffocated due to a malformed rib cage. Bone formation was blocked at an early chondrocytic stage. EFPrx1 mice lacked limb bones, had reduced calvaria, craniofacial abnormalities and polydactyly. We found that EF expression blocked differentiation of MSC at the pre-hypertrophic chondrocyte stage due to blocked TGF-β and enhanced Hedgehog signaling (down regulated tgfβrI/II, smad1/5, dlx5 and upregulated gli1/2 and caspase 3 mRNA expression). Moreover, EF expression blocked sox9, runx2 and osterix expression. These genes are important for bone differentian. We established MSC-like cells (MSCL) from EFPrx1 mice that self-renewed, but full transformation was absent.

We ought to test if the timing of EF induction plays a role, therefor we tested many time points later that the time point described before and we found that when Prx1Cre expression and consequently EWS/FLI1 induction was delayed to a time point after birth using a tamoxifen inducible system, a significant fraction of mice developed solid tumors up to 4 months after Tamoxifen induction. The histo-pathology of the tumors resembled PAS and VIMENTIN positive small round cell tumors, and genetically an EWS/FLI1 signature was seen similar to a patient-derived Ewing sarcoma gene expression pattern. These data suggest that EWS/FLI1 can drive oncogenesis without the need for additional genetic aberrations. We propose that this transgenic mouse model could resemble a faithful model for a solid EWS/FLI1 induced tumor phenocopying human Ewing sarcoma.

Citation Format: Tahereh Javaheri, Barbara Sax, Harini Nivarthi, Eleni Tomazou, Mario Mikula, Jan Pencik, Zahra Kazemi, Maximilian Kauer, Marc Wiedner, Jan Tuckermann, Michaela Schlederer, Lukas Kenner, Reinhold Erben, Malkolm Logan, Christine Hartmann, Heinrich Kovar, Richard Moriggl. A mouse model for small round cell tumors induced by the Ewing sarcoma oncogene EWS/FLI1. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 61. doi:10.1158/1538-7445.AM2014-61

Nosocomial outbreak of staphyloccocal scalded skin syndrome in neonates in England, December 2012 to March 2013

Staphylococcal scalded skin syndrome (SSSS) is a blistering skin condition caused by exfoliative toxin-producing strains of Staphylococcus aureus. Outbreaks of SSSS in maternity settings are rarely reported. We describe an outbreak of SSSS that occurred among neonates born at a maternity unit in England during December 2012 to March 2013. Detailed epidemiological and microbiological investigations were undertaken. Eight neonates were found to be infected with the outbreak strain of S. aureus, of spa type t346, representing a single pulsotype. All eight isolates contained genes encoding exfoliative toxin A (eta) and six of them contained genes encoding toxin B (etb). Nasal swabs taken during targeted staff screening yielded a staphylococcal carriage rate of 21% (17/80), but none contained the outbreak strain. Mass screening involving multi-site swabbing and pooled, enrichment culture identified a healthcare worker (HCW) with the outbreak strain. This HCW was known to have a chronic skin condition and their initial nasal screen was negative. The outbreak ended when they were excluded from work. This outbreak highlights the need for implementing robust swabbing and culture methodswhen conventional techniques are unsuccessful in identifying staff carrier(s). This study adds to the growing body of evidence on the role of HCWs in nosocomial transmission of S. aureus.

The effects of river run-off on water clarity across the central Great Barrier Reef

Changes in water clarity across the shallow continental shelf of the central Great Barrier Reef were investigated from ten years of daily river load, oceanographic and MODIS-Aqua data. Mean photic depth (i.e., the depth of 10% of surface irradiance) was related to river loads after statistical removal of wave and tidal effects. Across the ∼25,000 km(2) area, photic depth was strongly related to river freshwater and phosphorus loads (R(2)=0.65 and 0.51, respectively). In the six wetter years, photic depth was reduced by 19.8% and below water quality guidelines for 156 days, compared to 9 days in the drier years. After onset of the seasonal river floods, photic depth was reduced for on average 6-8 months, gradually returning to clearer baseline values. Relationships were strongest inshore and midshelf (∼12-80 km from the coast), and weaker near the chronically turbid coast. The data show that reductions in river loads would measurably improve shelf water clarity, with significant ecosystem health benefits.

Fine-needle trucut biopsy versus fine-needle aspiration cytology with ultrasound guidance in the abdomen

Historically, fine-needle aspiration cytology (FNAC) has varying sensitivity, specificity and accuracy in the diagnosis of abdominal lesions with a high insufficient sampling rate. We compared 20-G fine-needle trucut biopsy (FNTB) with FNAC results in the biopsy of solid abdominal tumours. A retrospective review of 171 (128x 20-G FNTB and 43x FNAC) ultrasound-guided biopsies of abdominal tumours on 157 patients (male : female 85:72, mean age 61.25 years) were carried out. One hundred and seventy-one biopsies were carried out: liver 109, pancreas 19, lymph node 10, omentum 5, right iliac fossa mass 6, adrenal 6 and others 16. An average of 2.06 and 1.97 passes (range 1-4) were carried out per FNTB and FNAC, respectively. A definitive diagnosis was made in 122/128 biopsies (95.3%) and 32/43 biopsies (74.4%) for FNTB and FNAC, respectively. Diagnoses consisted of metastatic liver disease (74/171), pancreatic adenocarcinoma (10/171), lymphoma (8/171) and others (33/171) and benign (29/171). No significant complications occurred in either group. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 87, 100, 100, 50, 84.4 and 93.1, 100, 100, 60, 71.4 for FNTB and FNAC, respectively. A greater and more consistent positive diagnosis rate is yielded by 20-G FNTB (95.3%) than FNAC (74.4%). The diagnostic accuracy of FNTB is 84.4% compared with 69.8% for FNAC. A greater insufficient sampling rate occurs with FNAC (25.6%) than with FNTB (4.7%). For abdominal biopsy, 20-G FNTB needles have a much higher yield than FNAC with no increase in complications. FNTB is the preferred choice, particularly where cytological assistance at the time of biopsy is unavailable.

Human Vero cytotoxigenic Escherichia coli (VTEC) O157 infection linked to birds

Vero cytotoxin-producing Escherichia coli O157 (VTEC O157) infections are a threat to public health. VTEC O157 has been isolated from gulls but evidence of transmission to humans from birds has not been reported. We recount an incident of VTEC O157 infection affecting two sibling children who had no direct contact with farm animals. An outbreak control team was convened to investigate the source of infection, its likely mode of transmission, and to advise on control measures. Human and veterinary samples were examined and the human isolates were found to be identical to an isolate from a sample of bird (rook) faeces. Cattle, rabbit and environmental samples were negative. This report provides evidence that birds may act as intermediaries for human infection with VTEC O157.

Development and implementation of a watershed management plan forLlac la Biche, Alberta, Canada

Lakeland County is experiencing increasing developmental pressures arising from the oil and gas boom at nearby Fort McMurray. There is increased industrial traffic passing through the county, and 600 new residential lots are proposed in 2005, almost double from 5 years ago. Deteriorating surface water quality has been a concern in the area due to an increase in development and agriculture, while excessive fish harvesting and winterkills have impacted commercial and recreational fisheries. Today, walleye and pike populations in the lake remain collapsed and restocking efforts have not been successful. Due to the lack of studies done on the watershed, the county is leading a multidisciplinary research study which includes a baseline water quality study, riparian health assessments, land use mapping and ground-truthing and projects with the local health authority. This research has been summarized in a comprehensive state of the watershed report, which will be used to complete a watershed management plan for the Lac la Biche watershed. Recommendations from the state of the watershed report and watershed management plan will also be incorporated into municipal planning documents and recommend changes to the Municipal Government Act itself.

The effects of lactation on the feeding behaviour and activity patterns of free-ranging female koalas (Phascolarctos cinereus Goldfuss)

The free-ranging feeding behaviour and activity patterns of three lactating and two non-lactating female koalas (Phascolarctos cinereus) were investigated using acoustically sensitive radio-telemetry. Lactating females were found to consume more leaf material, masticate more per leaf and at a greater rate, and perform more ingestive and mercyism mastications per 24 h than non-lactating females. Results suggest than female koalas are 'income breeders' that compensate for the higher energetic demands of lactation by increasing intake and, to a lesser degree, investing more in each mouthful so as to produce a shift in digesta particle size distribution in favour of more finer particles. Compared with non-lactating females, lactating female koalas were also found to spend more time moving within trees, feeding per 24 h and per bout, and less time resting and sleeping per 24 h, although the proportion of active time spent feeding was similar (~80%). This implies that female koalas adopt a 'time minimizing strategy whereby activity budgets respond to current requirements. Lactation-compensation mechanisms are compared with those reported for koalas with high tooth wear, and the capacity of aging female koalas to compensate for lactation are discussed.

How do microbiology consultants undertake their jobs? A survey of consultant time and tasks in South West England

AIMS

To measure the total consultant medical microbiologist (CMM) weekly workload, to identify time spent on different activities, and to differentiate those tasks that were viewed by a consensus of consultants as core activities from those that could be accorded a lower priority.

METHODS

A self administered questionnaire completed by consultant medical microbiologists in the Public Health Laboratory Service South West Group.

RESULTS

Reported hours worked by respondents ranged from 41 to 65 hours each week, excluding on call activities. Eleven of 20 respondents reported working in excess of 48 hours each week. There was no correlation between hours worked and laboratory workload as measured by numbers of specimens. Clinical liaison, result authorisation, infection control, and management activities took up most time. Working practices varied widely between individuals, partly reflecting their differing roles in the laboratory. A consensus was reached regarding the relative importance and priority of many regular CMM activities.

CONCLUSIONS

Consultant microbiologists can identify, with consensus, both high and lower priority activities in their daily practice. If such clinical priorities can be more widely agreed across the profession, this would provide a rational approach to workload control.

The effects of tooth wear on the activity patterns of free-ranging koalas (Phascolarctos cinereus Goldfuss)

The free-ranging activity patterns of five adult males and one sub-adult male koala (Phascolarctos cinereus) with varying degrees of tooth wear were investigated using acoustically sensitive radio-telemetry. Increased tooth wear was found to be associated with a significant decrease in the amount of time spent sleeping and being inactive. Furthermore, compared with individuals with low degrees of tooth wear, individuals with high tooth wear were found to spend considerably less time moving within and between trees, and had home ranges an order of magnitude smaller. Hence, feeding compensations were found to come at the expense of other activities such as sociality and therefore have important consequences for reproductive output. Individuals with high tooth wear also spent longer feeding per bout, and spaced feeding bouts out more evenly throughout a 24-h period, thereby exhibiting reduced degrees of nocturnality. The sub-adult was found to range over a disproportionately large area and spend a relatively large amount of time moving between trees, indicative of a dispersing individual. Moreover, the activity patterns of this individual were found to differ slightly from the adult trends and were perhaps affected by the extra energetic demands associated with dispersal.

TaCRK3 encodes a novel Theileria annulata protein kinase with motifs characteristic of the family of eukaryotic cyclin dependent kinases: a comparative analysis of its expression with TaCRK2 during the parasite life cycle

The TaCRK3 gene from the bovine apicomplexan parasite Theileria annulata, encodes a 46 kDa polypeptide with strong homology to the eukaryotic family of cyclin-dependent kinases. TaCRK3 does not show significant alignment with any particular CDK group, other than the Pfmrk kinases from the related apicomplexans Plasmodium falciparum and Plasmodium yoelii. It has a putative bipartite nuclear localization signal and is located to parasite nuclei by IFAT. Protein levels are constitutive throughout differentiation of the intra-lymphocytic macroschizont. This contrasts with the expression pattern of TaCRK2 (Kinnaird et al., 1996, Mol. Microbiol., 22, 293-302) which is closely related to the eukaryotic CDK1 /2 families involved in regulation of cell cycle progression. TaCRK2 is also located to the parasite nuclei but has no nuclear localization signal and exhibits transient up-regulation in protein levels during mid-merogony. However compared to TaCRK3, it shows down-regulation near the end of merogony. We predict that TaCRK3 may have a role in regulation of gene transcription while TaCRK2 is more likely to be involved in control of parasite nuclear division.

Cholesterol modification of sonic hedgehog is required for long-range signaling activity and effective modulation of signaling by Ptc1

Sonic hedgehog (Shh) signaling from the posterior zone of polarizing activity (ZPA) is the primary determinant of anterior-posterior polarity in the vertebrate limb field. An active signal is produced by an autoprocessing reaction that covalently links cholesterol to the N-terminal signaling moiety (N-Shh(p)), tethering N-Shh(p) to the cell membrane. We have addressed the role played by this lipophilic modification in Shh-mediated patterning of mouse digits. Both the distribution and activity of N-Shh(p) indicate that N-Shh(p) acts directly over a few hundred microns. In contrast, N-Shh, a form that lacks cholesterol, retains similar biological activity to N-Shh(p), but signaling is posteriorly restricted. Thus, cholesterol modification is essential for the normal range of signaling. It also appears to be necessary for appropriate modulation of signaling by the Shh receptor, Ptc1.

Developing a European Internet and kiosk-based health information system

A consortium of partner organisations (universities, health care organisations and information technology companies) from Northern Ireland, Germany, Portugal and Italy have collaborated to develop a multi-lingual, multi-media Internet and kiosk-based health information system in cardiology and skin cancer. The project, CATCH II (Citizens Advisory System based on Telematics for Communication and Health), has been funded by the European Commission under the Fourth Framework Research and Development TELEMATICS Applications Program (TAP), Health Care Sector. In this paper we provide an overview of the system and the methodological approach adopted. Key characteristics with respect to the technical architecture and flexible customisation of different web and kiosk-based versions will be presented. In particular, the development of dedicated software for the procurement, structuring and management of the information knowledge-base is illustrated. Some of the most interesting findings from a cross-national study of health information needs on the internet are presented along with information on the validation of the system by the general public, content providers and health care authorities.

Acute sensitivity of landslide rates to initial soil porosity

Some landslides move imperceptibly downslope, whereas others accelerate catastrophically. Experimental landslides triggered by rising pore water pressure moved at sharply contrasting rates due to small differences in initial porosity. Wet sandy soil with porosity of about 0.5 contracted during slope failure, partially liquefied, and accelerated within 1 second to speeds over 1 meter per second. The same soil with porosity of about 0.4 dilated during failure and slipped episodically at rates averaging 0.002 meter per second. Repeated slip episodes were induced by gradually rising pore water pressure and were arrested by pore dilation and attendant pore pressure decline.

Synthetic glycopeptide-based delivery systems for systemic gene targeting to hepatocytes

PURPOSE

To design, synthesize, and test synthetic glycopeptide-based delivery systems for gene targeting to hepatocytes by systemic administration.

METHODS

All peptides were synthesized by the solid phase method developed using Fmoc chemistry on a peptide synthesizer. The binding of galactosylated peptides to HepG2 cells and accessibility of the galactose residues on particle surface was demonstrated by a competition assay using 125I-labeled asialoorosomucoid and RCA lectin agglutination assay, respectively. DNA plasmid encoding chloramphenicol acetyl transferase (CAT) gene was complexed with a tri-galactosylated peptide (GM245.3) or tri-galactosylated lipopeptide (GM246.3) in the presence of an endosomolytic peptide (GM225.1) or endosomolytic lipopeptide (GM227.3) to obtain DNA particles of 100-150 nm in size. The plasmid/peptide complexes were added to HepG2 cell cultures or intravenously administered by tail vein injection into normal mice or rats. Plasmid uptake and expression was quantified by qPCR and ELISA, respectively.

RESULTS

Multiple antennary glycopeptides that have the ability to condense and deliver DNA plasmid to hepatocytes were synthesized and complexed with DNA plasmid to obtain colloidally stable DNA/peptide complexes. Addition of DNA/GM245.3/GM225.1 peptide complexes (1:3:1 (-/+/-)) to HepG2 cell cultures yielded CAT expression in transfected cells. The transfection efficiency was significantly reduced in the absence of galactose ligand or removal of endosomolytic peptide. Intravenous administration of DNA/GM245.3 peptide complexes (1:0.5 (-/+)) into the tail vein of normal rats yielded DNA uptake in the liver. Substitution of GM245.3 by galactosylated lipopeptide GM246.3 resulted in more stable DNA particles, and a 10-fold enhancement in liver plasmid uptake. CAT expression was detectable in liver following intravenous administration of DNA/GM246.3 complexes. Addition of endosomolytic lipopeptide GM227.3 into the complexes (DNA/ GM246.3/GM227.3 (1:0.5:1 (-/+/-))) yielded a 5-fold increase in CAT expression. Liver expression was 8-fold and 40-fold higher than lung and spleen, respectively, and localized in the hepatocytes only. The transfection efficiency in liver was enhanced by increasing DNA dose and injection volume. The plasmid uptake and expression in liver using DNA/GM246.3/GM227.3 complexes was 100-200-fold higher than DNA formulated in glucose. Tissue examination and serum biochemistry did not show any adverse effect of the DNA/GM246.3/ GM227.3 (1:0.5:1 (-/+/-)) complexes after intravenous delivery.

CONCLUSIONS

Gene targeting to hepatocytes was achieved by systemic administration of a well-tolerated synthetic glycopeptide-based delivery system. The transfection efficiency of this glycopeptide delivery system was dependent on peptide structure, endosomolytic activity, colloidal particle stability, and injection volume.

Loss of matrix metalloproteinase 9 activity in Theileria annulata-attenuated cells is at the transcriptional level and is associated with differentially expressed AP-1 species

The schizont stage of the protozoan parasite Theileria annulata reversibly transforms bovine monocytes into an immortalised and metastatic state. We have been studying T. annulata induction of host matrix metalloproteinases (MMP) which are involved in parasite dissemination and pathogenesis. We have observed that prolonged in vitro culture of T. annulata-infected cell lines results in their attenuation and this process is associated with alterations in both host and parasite gene expression. In particular, a loss in bovine MMP expression in later passage cultures suggests that these parasite-induced MMPs are virulence factors. As a means to further our understanding of the attenuation process we examine in detail the parasite-induced differential expression of one particular bovine proteinase, MMP9, in non-attenuated (p58) and attenuated (p158) passage levels of the Ode vaccine line. We show here that MMP9 expression is regulated at the transcriptional level and we suggest that a particular parasite-induced AP-1 recognition transcription factor present in the Ode non-attenuated line may have a role to play in the expression of this host gene.

A secondary school outbreak of mumps following the childhood immunization programme in England and Wales

Since the introduction of routine measles, mumps and rubella immunization for children in England and Wales in 1988, the incidence of mumps has declined steadily. We describe an outbreak of mumps in 1996 attacking 34 of a cohort of 98 schoolchildren born in 1982 and 1983. This is the largest outbreak in the UK since the introduction of the vaccine into the childhood immunization schedule. Salivary IgM assay was used as a simple, minimally invasive test to confirm the diagnosis. The occurrence of the outbreak demonstrates that British children who were just too old to receive mumps immunization in 1988 continue to be at risk of this disease as a result of diminished natural exposure. Further cases and outbreaks in this cohort are to be expected. Cohorts born before 1982 appear to be at less risk, presumably because of naturally acquired infection before the introduction of immunization.

Chamber-specific cardiac expression of Tbx5 and heart defects in Holt-Oram syndrome

To further define the role of a T-box transcription factor, Tbx5, in cardiac development, we have examined its expression in the developing mouse and chick heart and correlated this pattern with cardiac defects caused by human TBX5 mutations in Holt-Oram syndrome. Early in the developing heart, Tbx5 is uniformly expressed throughout the entire cardiac crescent. Upon formation of the linear heart tube, Tbx5 is expressed in a graded fashion, stronger near the posterior end and weaker at the anterior end. As the heart tube loops, asymmetric Tbx5 expression continues; Tbx5 is expressed in the presumptive left ventricle, but not the right ventricle or outflow tract. This pattern of expression is maintained in more mature hearts. Expression in the ventricular septum is restricted to the left side and is contiguous with left ventricular free wall expression. Trabeculae, vena cavae (inferior and superior), and the atrial aspect of the atrioventricular valves also express high levels of Tbx5. These patterns of Tbx5 expression provide an embryologic basis for the prevalence of atrial septal defects (ostium primum and secundum), ventricular muscular septal defects, and left-sided malformations (endocardial cushion defects, hypoplastic left heart, and aberrant trabeculation) observed in patients with Holt-Oram syndrome.

Role of Pitx1 upstream of Tbx4 in specification of hindlimb identity

In spite of recent breakthroughs in understanding limb patterning, the genetic factors determining the differences between the forelimb and the hindlimb have not been understood. The genes Pitx1 and Tbx4 encode transcription factors that are expressed throughout the developing hindlimb but not forelimb buds. Misexpression of Pitx1 in the chick wing bud induced distal expression of Tbx4, as well as HoxC10 and HoxC11, which are normally restricted to hindlimb expression domains. Wing buds in which Pitx1 was misexpressed developed into limbs with some morphological characteristics of hindlimbs: the flexure was altered to that normally observed in legs, the digits were more toe-like in their relative size and shape, and the muscle pattern was transformed to that of a leg.

Prescribing guidelines based on a flexible scope of practice

Nurse practitioners (NPs) are in demand nationwide as primary care providers both in the inpatient and outpatient settings. Lack of prescriptive privileges and/or a narrow scope of practice can be practice limiting. This article provides a written template for prescribing authority, generic scope of practice, and furnishing policy, including evaluative process, for nurse practitioners who wish to obtain prescriptive privileges. Developed at the Palo Alto Veterans Affairs Health Care System, these documents can be used by NPs nationwide. They can be adapted to each provider's unique practice, whether in the hospital, clinic, or private practice setting.

Effect of sevoflurane concentration on inhalation induction of anaesthesia in the elderly

We have conducted a randomized, double-blind comparison of 4% and 8% sevoflurane for induction of anaesthesia in unpremedicated patients aged more than 60 yr. Sevoflurane was inhaled in 50% nitrous oxide using a vital capacity breath technique, and mean, systolic and diastolic arterial pressures and heart rate were monitored continuously using a Finapres cuff. In the 8% sevoflurane group, time to successful laryngeal mask insertion was significantly shorter (mean 168 (SD 34) s vs 226 (62) s; P < 0.01) and achieved more often at the first attempt than in the 4% sevoflurane group. Arterial pressures were lower in the 8% group, but this was not significant. No patient had apnoea lasting longer than 1 min. A total of 69% of patients described induction as pleasant and 85% would choose to have it again. We conclude that compared with 8% sevoflurane, the use of 4% sevoflurane in the elderly resulted in greater cardiovascular stability but at the cost of prolonged and occasionally unsuccessful induction.

Haploinsufficiency of MSX1: a mechanism for selective tooth agenesis

Previously, we found that the cause of autosomal dominant selective tooth agenesis in one family is a missense mutation resulting in an arginine-to-proline substitution in the homeodomain of MSX1. To determine whether the tooth agenesis phenotype may result from haploinsufficiency or a dominant-negative mechanism, we have performed biochemical and functional analyses of the mutant protein Msx1(R31P). We show that Msx1(R31P) has perturbed structure and reduced thermostability compared with wild-type Msx1. As a consequence, the biochemical activities of Msx1(R31P) are severely impaired, since it exhibits little or no ability to interact with DNA or other protein factors or to function in transcriptional repression. We also show that Msx1(R31P) is inactive in vivo, since it does not display the activities of wild-type Msx1 in assays of ectopic expression in the limb. Furthermore, Msx1(R31P) does not antagonize the activity of wild-type Msx1 in any of these assays. Because Msx1(R31P) appears to be inactive and does not affect the action of wild-type Msx1, we propose that the phenotype of affected individuals with selective tooth agenesis is due to haploinsufficiency.

Biodistribution and gene expression of lipid/plasmid complexes after systemic administration

The objectives of this study were to investigate the influence of physicochemical properties of lipid/plasmid complexes on in vivo gene transfer and biodistribution characteristics. Formulations based on 1,2-di-O-octadecenyl-3-trimethylammonium propane (DOTMA) and novel biodegradable cationic lipids, such as ethyl dioleoyl phosphatidylcholine (EDOPC), ethyl palmitoyl myristyl phosphatidylcholine (EPMPC), myristyl myristoyl carnitine ester (MMCE), and oleyl oleoyl L-carnitine ester (DOLCE), were assessed for gene expression after tail vein injection of lipid/plasmid complexes in mice. Gene expression was influenced by cationic lipid structure, cationic lipid-to-colipid molar ratios, plasmid-to-lipid charge ratios, and precondensation liposome size. Detectable levels of human growth hormone (hGH) in serum, human factor IX (hFIX) in plasma, and chloramphenicol acetyltransferase (CAT) in the lung and liver were observed with positively charged lipid/plasmid complexes prepared from 400-nm extruded liposomes with a cationic lipid-to-colipid ratio of 4:1 (mol/mol). Intravenous administration of lipid/CAT plasmid complexes resulted in distribution of plasmid DNA mainly to the lung at 15 min after injection. Plasmid DNA accumulation in the liver increased with time up to 24 hr postinjection. There was a 10-fold decrease in the amount of plasmid DNA in the lung at 15 min after injection, when the lipid/plasmid complex charge ratio was decreased from 3:1 to 0.5:1 (+/-). Bright fluorescent aggregates were evident in in vivo-transfected lung with the positively charged pCMV-CAT/DOLCE:dioleyl phosphatidylethanolamine (DOPE) (1:1, mol/mol) complexes, while more discrete punctate fluorescence was observed with a 4:1 molar ratio of cationic lipid:colipid formulations. Preinjection of polyanions such as plasmid, dextran sulfate, polycytidic acid, and polyinosinic acid decreased hGH expression, whereas the preinjection of both positively charged and neutral liposomes had no effect on hGH serum levels. Of the cationic lipids tested, DOLCE was found to be the most effective potentially biodegradable cationic lipid. A correlation between gene expression and cationic lipid:colipid ratios and lipid-to-plasmid charge ratio was also observed for DOTMA- and DOLCE-based formulations.

Expanding nurse practitioner scope of practice within the Veterans Affairs Palo Alto Health Care System

Healthcare priorities and use have changed dramatically over the last several years. Expansion of the nurse practitioner (NP) role has been a hallmark of the restructuring efforts, which have emphasized primary care and the use of nonphysician specialists. NPs are practicing in a wider range of settings than ever before, including acute hospital settings, outpatient clinics, and specialty services. While the Veterans Health Administration (VHA) has employed NPs since the early 1970s, their practice has been limited at many VHA medical centers. Such was the case at the Veterans Affairs Palo Alto Health Care System (VAPAHCS), when physicians produced a scope of practice (SOP) for NPs that was practice limiting. This article highlights the historical progress of NPs in defining their practice, discusses barriers to NP practice at the VAPAHCS, outlines strategies to overcome barriers, and discusses future possibilities for advanced practice nursing within the VA.

The transcription factor Pitx2 mediates situs-specific morphogenesis in response to left-right asymmetric signals

The mechanism by which asymmetric signals induce left-right-specific morphogenesis has been elusive. Pitx2 encodes a transcription factor expressed throughout the left lateral plate mesoderm and subsequently on the left side of asymmetric organs such as the heart and gut during organogenesis in the chick embryo. Pitx2 is induced by the asymmetric signals encoded by Nodal and Sonic hedgehog, and its expression is blocked by prior treatment with an antibody against Sonic hedgehog. Misexpression of Pitx2 on the right side of the embryo is sufficient to produce reversed heart looping and heart isomerisms, reversed body rotation, and reversed gut situs.

Differential regulation of T-box and homeobox transcription factors suggests roles in controlling chick limb-type identity

The wing and the leg of the chick, although homologous structures, have characteristic patterns of skeletal elements, muscles, tendons, featherbuds and scales. Despite recent advances in understanding the common genetic pathways patterning the wing and leg, the molecular nature of the specification of limb-type identity has remained elusive. Embryological experiments have indicated the existence of limb-specific territories in the flank. In the newt, deviation of nerves from the limb into the flank can induce ectopic limbs to form from this tissue. In the chick, Fibroblast growth factor (FGF)-soaked beads applied to the flank can induce ectopic formation of limbs from the surrounding tissue. In both cases, the type of limb that forms, either a wing/forelimb or leg/hindlimb, is dependent upon the location to which the limb-inducing signal is applied. We have isolated and characterised three candidate genes for controlling limb identity in the chick. Two T-box transcription factors, cTbx4 and cTbx5, are expressed in a restricted manner in the leg bud and wing buds, respectively. cPtx1, a member of the Otx-related subclass of paired-type homeodomain proteins, is expressed exclusively in the leg bud. Using FGF to induce ectopic limb buds of wing, leg and intermediate identity, we show that early expression of cTbx5, cTbx4 and cPtx1 in the induced limb buds correlates with later wing- or leg-type identity of ectopic limbs. We observe a general correlation between the location of an ectopic outgrowth induced by FGF and the identity of the resulting limb but, significantly, we report that there is no definitive rostral-caudal level that divides the ectopic wing and leg territories.

Targeted gene misexpression in chick limb buds using avian replication-competent retroviruses

The methods and applications for using avian replication-competent retroviruses to target gene misexpression in the developing limb bud of the chicken are described. These viruses provide the means to exploit the strengths of the chick as a model system in experimental embryology in conjunction with a genetic approach for ectopically expressing a gene of interest. The applications and strengths of the system are detailed. All the steps required to produce a virus carrying a transgene of interest and the methodologies behind designing and carrying out misexpression strategies are outlined, and some useful techniques for analyzing infected embryos are described.

Postnatal pup brain dopamine depletion inhibits maternal behavior

The interactions between dams and their pups and among siblings were investigated in litters with (a) all pups depleted of striatal dopamine by 6-hydroxydopamine (6-OHDA on PND3), (b) all pups treated with vehicle, or (c) half of the pups depleted of dopamine and the other half treated with vehicle. On PND10, two sets of four pups from each litter were videotaped in a novel environment with the dam:pup and maternal behaviors were later scored by blind observers. We observed a 70% decrease in striatal dopamine in 6-OHDA-treated pups but found no effect of treatment on pup weight gain. Dams with some or all DA-depleted pups (a) were slower to retrieve a pup and establish a nest, (b) retrieved pups less frequently, and (c) spent less time huddling with pups than dams with only vehicle-treated pups. When compared with DA-depleted pups in homogeneous litters, DA-depleted pups in mixed litters were less hyperactive and spent more time huddling with other pups than in isolation. These results suggest that DA-depleted pups receive compromised maternal care but can benefit from interactions with normal siblings.