Concordance of diagnostic modalities in atypical skin and soft tissue infections in hospitalized patients

Skin and soft tissue infections (SSTIs) have high rates of morbidity and mortality worldwide but lack reliable standards for diagnostic workup. As a result, atypical infections, more prevalent among immunocompromised patients, can be missed due to deviance from classic features only to be revealed later through inconsistently performed ancillary studies. Our objectives included to evaluate the sensitivities of clinical impression, histopathology, tissue culture, and molecular and non-molecular ancillary tests in diagnosing inpatient SSTIs, as well as to qualitatively discuss the unusual features making a subset of infections "atypical." To do so, we retrospectively reviewed the histopathologic reports and charts of inpatient dermatologic consults at a single tertiary care institution over a 3-year period. We identified a total of 111 cases of SSTIs evaluated by the inpatient dermatology consultation service with concurrent skin or soft tissue biopsy, with 32.4% representing atypical infections. Among these, clinical impression suggested infection in 9(25.0%), routine histopathology in 21(58.3%), specialized stains for microorganisms in 22(68.8%), and tissue culture in 15(68.2%). Due to incomplete picture that each modality by itself creates, we conclude that clinicians and pathologists should carry a low threshold for including SSTIs in their differential diagnoses and should evaluate with skin biopsy, special stains for microorganisms, and ancillary studies, particularly in critically ill individuals who necessitate timely diagnoses.

Influence of systemic copper toxicity on early development and metamorphosis in Xenopus laevis

The primary objective of the present study was to examine the influence of early systemic toxicity resulting from copper (Cu) exposure on metamorphic processes in Xenopus laevis. A 28-day exposure study with copper, initiated at developmental stage 10, was performed using test concentrations of 3.0, 9.0, 27.2, 82.5, and 250 μg Cu/L. The primary endpoints included mortality, developmental stage, embryo-larval malformation, behavioral effects, hindlimb length (HLL), growth (snout-vent length [SVL] and wet body weight), and histopathology. The 28-day LC50 value with 95% confidence intervals was 61.2 (51.4-72.9) μg Cu/L with 250 μg Cu/L resulting in complete lethality. Developmental arrest in the 82.5 and delay in the 27.2 μg Cu/L treatments was observed as early as study day 10 continuing throughout the remainder of exposure. SVL-normalized HLL, body weight, and SVL in the 27.2 and 82.5 μg Cu/L treatments were significantly decreased relative to control. At 82.5 μg Cu/L, and thyroid gland size was markedly reduced when compared with controls consistent with the stage of developmental and growth arrest. Concentration-dependent findings in the intestine, liver, gills, eyes, and pharyngeal mucosa were consistent with non-endocrine systemic toxicity. These were prevalent in the 9.0 and 27.2 μg Cu/L treatment groups but were minimally evident or absent in the 82.5 μg/L group, which was attributed to developmental arrest. In conclusion, developmental delay in larvae exposed to 27.2 and 82.5 μg Cu/L was the result of systemic toxicity occurring in early development prior hypothalomo-pituitary-thyroid axis (HPT)-driven metamorphosis and was not indicative of endocrine disruption.

The Emirates Mars Mission

The Emirates Mars Mission (EMM) was launched to Mars in the summer of 2020, and is the first interplanetary spacecraft mission undertaken by the United Arab Emirates (UAE). The mission has multiple programmatic and scientific objectives, including the return of scientifically useful information about Mars. Three science instruments on the mission's Hope Probe will make global remote sensing measurements of the Martian atmosphere from a large low-inclination orbit that will advance our understanding of atmospheric variability on daily and seasonal timescales, as well as vertical atmospheric transport and escape. The mission was conceived and developed rapidly starting in 2014, and had aggressive schedule and cost constraints that drove the design and implementation of a new spacecraft bus. A team of Emirati and American engineers worked across two continents to complete a fully functional and tested spacecraft and bring it to the launchpad in the middle of a global pandemic. EMM is being operated from the UAE and the United States (U.S.), and will make its data freely available.

Community interventions for improving adult mental health: mapping local policy and practice in England

BACKGROUND

Public mental health (PMH) aims to improve wellbeing and prevent poor mental health at the population level. It is a global challenge and a UK priority area for action. Communities play an important role in the provision of PMH interventions. However, the evidence base concerning community-based PMH interventions is limited, meaning it is challenging to compare service provision to need. Without this, the efficient and equitable provision of services is hindered. Here, we sought to map the current range of community-based interventions for improving mental health and wellbeing currently provided in England to inform priority areas for policy and service intervention.

METHOD

We adopted an established mapping exercise methodology, comparing service provision with demographic and deprivation statistics. Five local authority areas of England were selected based on differing demographics, mental health needs and wider challenging circumstances (i.e. high deprivation). Community-based interventions were identified through: 1) desk-based research 2) established professional networks 3) chain-referral sampling of individuals involved in local mental health promotion and prevention and 4) peer researchers' insight. We included all community-based, non-clinical interventions aimed at adult residents operating between July 2019 and May 2020.

RESULTS

407 interventions were identified across the five areas addressing 16 risk/protective factors for PMH. Interventions for social isolation and loneliness were most prevalent, most commonly through social activities and/or befriending services. The most common subpopulations targeted were older adults and people from minority ethnic backgrounds. Interventions focusing on broader structural and environmental determinants were uncommon. There was some evidence of service provision being tailored to local need, though this was inconsistent, meaning some at-risk groups such as men or LGBTQ+ people from minority ethnic backgrounds were missed. Interventions were not consistently evaluated.

CONCLUSIONS

There was evidence of partial responsiveness to national and local prioritising. Provision was geared mainly towards addressing social and individual determinants of PMH, suggesting more integration is needed to engage wider service providers and policy-makers in PMH strategy and delivery at the community level. The lack of comprehensive evaluation of services to improve PMH needs to be urgently addressed to determine the extent of their effectiveness in communities they serve.

Using a Sweating Residuum/socket Interface Simulator for the Evaluation of Sweat Management Liners in Lower Limb Prosthetics

BACKGROUND

Lab-based simulators can help to reduce variability in prosthetics research. However, they have not yet been used to investigate the effects of sweating at the residuum-liner interface. This work sought to create and validate a simulator to replicate the mechanics of residual limb perspiration. The developed apparatus was used to assess the effects of perspiration and different liner designs.

METHODOLOGY

By scanning a cast, an artificial residuum was manufactured using a 3D-printed, transtibial bone model encased in silicone, moulded with pores. The pores allowed water to emit from the residuum surface, simulating sweating. Dry and sweating cyclic tests were performed by applying compressive and tensile loading, while measuring the displacement of the residuum relative to the socket. Tests were conducted using standard and perforated liners.

FINDINGS

Although maximum displacement varied between test setups, its variance was low (coefficient of variation <1%) and consistent between dry tests. For unperforated liners, sweating increased the standard deviation of maximum displacement approximately threefold (0.04mm v 0.12mm, p<0.001). However, with the perforated liner, sweating had little effect on standard deviation compared to dry tests (0.04mm v 0.04mm, p=0.497).

CONCLUSIONS

The test apparatus was effective at simulating the effect of perspiration at the residual limb. Moisture at the skin-liner interface can lead to inconsistent mechanics. Perforated liners help to remove sweat from the skin-liner interface, thereby mitigating these effects.

Community interventions improving mental health in minority ethnic adults in the UK: a scoping review

Background

Black, Asian and Minority Ethnic (BAME) groups in the UK are disproportionately affected by poor mental health. This scoping review sought to determine the effectiveness of community interventions designed to improve the metal health and wellbeing of adults from BAME groups in the UK.

Methods

We searched six electronic academic databases for studies published between 1990- 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and the Template for Intervention description and replication (TIDieR) guide was used for data extraction and intervention descriptions. Quality was assessed using Cochrane Risk of Bias tools. Grey literature results were deemed beyond the scope of this review; numerous (&gt;50) small scale community interventions were found without available outcomes data.

Results

Of 4,501 studies, seven met the inclusion criteria: four randomised control trials, one pre and post pilot study, one cross sectional study and one ethnographic study. Interventions included therapy-style sessions, peer-support groups, educational materials, gym access, and a family services programme. Common components included a focus on tackling social isolation, using lay health workers from within the community, signposting, and cultural adaptation. Only three studies reported a statistically significant positive outcome on mental health and six were appraised as having a high risk of bias. Knowledge gaps emerged around effective interventions for men, some BAME groups, and tackling the wider determinants of mental health.

Conclusions

There is a paucity of high-quality evidence on community interventions focussed on improving public mental health among BAME groups. Decision makers need scientific evidence to inform effective approaches to mitigating health disparities. Our next steps are to map promising community activities and interventions that are currently being provided to help identify emerging evidence.

Key messages

Evidence is limited and weak on community interventions that reduce mental health burden among minority ethnic people. Evaluation of promising interventions at scale can close the evidence gap.

Using Perforated Liners to Combat the Detrimental Effects of Excessive Sweating in Lower Limb Prosthesis Users

BACKGROUND

Excessive sweating of the residual limb has a substantial effect on the daily activities of people with lower limb amputation. Prosthetic liners offer protection and comfort to sensitive areas but often exacerbate perspiration. They act as insulators, trapping sweat on the skin's surface to the detriment of skin health. Recently, liners with perforations have been developed, allowing the moisture to escape. The goal of this study was to assess the impact of such liners.

METHODS

A sample group of 13 patients with unilateral transtibial amputation, who wore a perforated liner (PL) as part of their current prescription, was compared to 20 control patients who wore non-perforated liners (NPL). During their routine appointments, they completed a survey of scientifically validated outcome measures relating to their limb health, pain and the impact on daily life over a 12-month period.

RESULTS

Patients using the PL had healthier residual limbs, reporting higher scores on questions relating to limb health, experiencing fewer skin issues (p<0.001) and estimating a 61.8% lower rating in perceived sweat (p=0.004). Perhaps consequentially, there was a lower incidence of residual (p=0.012) and phantom (p=0.001) limb pain when compared to the control group. The prevalence of individual issues affecting the residual limbs of PL users was also lower. Of the issues that remained, only 23% were attributed to sweating in PL users, compared to 49% for the NPL group (p=0.066). PL users missed fewer days of work in the year (2.4 vs 11.6, p=0.267) and were also limited on fewer days (1.4 vs 75.4, p=0.009).

CONCLUSION

The use of perforated liners shows much promise within prosthetic care, significantly improving the health of the residual limb. The observed effects on perceived sweat reduction, residual skin health, pain levels and patient limitation suggest that perforated liners are highly beneficial to patients.

Genotyping-by-Sequencing for Analysis of the Genetic Variation of Podosphaera xanthii, Incitant of Cucurbit Powdery Mildew

This research was conducted to identify species causing powdery mildew on cucurbits and to determine genetic variations among isolates of the pathogen. We collected 109 isolates from six cucurbit species hosts (Cucumis melo, Cucumis sativus, Cucurbita maxima, Cucurbita moschata, Cucurbita pepo, and Lagenaria siceraria) in California, Illinois, Indiana, Michigan, New York, Texas, Washington, and Wisconsin in the United States and in Italy. By sequencing the internal transcribed spacer region of the nuclear rDNA of these 109 isolates, Podosphaera xanthii was found as the only species causing powdery mildew on cucurbits in the United States. Genotyping-by-sequencing was applied to these 109 isolates to investigate their genetic diversity, which showed a trend of isolates clustering from New York and Italy. In addition, the virulence of 36 isolates was compared and a significant difference (P < 0.0001) was found among them. Furthermore, results of the virulence tests of 28 isolates from Illinois showed significant effects of collection years, hosts, and locations on the virulence of the isolates.

The Influence of Hydraulic Ankles and Microprocessor-control on the Biomechanics of Trans-tibial Amputees During Quiet Standing on a 5° Slope

BACKGROUND

Lower limb amputees have a high incidence of comorbidities, such as osteoarthritis, which are believed to be caused by kinetic asymmetries. A lack of prosthetic adaptation to different terrains requires kinematic compensations, which may influence these asymmetries.

METHOD

Six SIGAM grade E-F trans-tibial amputees (one bilateral) wore motion capture markers while standing on force plates, facing down a 5° slope. The participants were tested under three prosthetic conditions; a fixed attachment foot (FIX), a hydraulic ankle (HYD) and a microprocessor foot with a 'standing support' mode (MPF). The resultant ground reaction force (GRF) and support moment for prosthetic and sound limbs were chosen as outcome measures. These were compared between prosthetic conditions and to previously captured able-bodied control data.

RESULTS

The distribution of GRF between sound and prosthetic limbs was not significantly affected by foot type. However, the MPF condition required fewer kinematic compensations, leading to a reduction in sound side support moment of 59% (p=0.001) and prosthetic side support moment of 43% (p=0.02) compared to FIX. For the bilateral participant, only the MPF positioned the GRF vector anterior to the knees, reducing the demand on the residual joints to maintain posture.

CONCLUSIONS

For trans-tibial amputees, loading on lower limb joints is affected by prosthetic foot technology, due to the kinematic compensations required for slope adaptation. MPFs with 'standing support' might be considered reasonable and necessary for bilateral amputees, or amputees with stability problems due to the reduced biomechanical compensations evident.

Treatment gap and mental health service use among Syrian refugees in Turkey

Introduction

Turkey hosts the highest number of Syrian refugees in Europe. Refugees are often vulnerable to situational forms of psychosocial distress as a consequence of exposure to war and violence which may result in more profound mental health problems if no treatment is sought. The aim of this study is to report evidence on mental health and psychosocial support (MHPSS) needs, access and barriers to MHPSS care among Syrians refugees living in Istanbul, Turkey.

Methods

A cross-sectional survey was conducted among Syrian refugees aged 18 years or over in Istanbul (Sultanbeyli) between February and May 2018. Data among 1’678 Syrian refugees were collected on mental health outcomes using the Posttraumatic Stress Disorder (PTSD) Checklist (PCL-5) and the Hopkins Symptoms Checklist (HSCL-25) for depression and anxiety. We also collected data on health care utilization, barriers to seeking and continuing care as well as knowledge and attitudes towards mental health. Descriptive analyses were used.

Results

The prevalence of PTSD, depression and anxiety was 19.6%, 34.7% and 36.1% respectively. The treatment gap was 89% for PTSD, 90% for anxiety and 88% for depression. 249 respondents (15%) screened positive for either PTSD, depression or anxiety in our survey and self-reported emotional/behavioural problems since arriving in Sultanbeyli. Several structural and attitudinal barriers for not seeking care were reported.

Conclusions

To overcome the treatment gap, mental health care programmes need to be more responsive to the needs of Syrian refugees. Barriers to seeking and continuing care can be overcome by providing MHPSS services in the community which facilitate access to care. Community-based programmes of care should be supported by activities which increase awareness about mental health issues and tackle negative attitudes towards mental illness.

Key messages

This study provides the first nationally representative data on the mental health of Syrian refugees in Turkey, and shows that refugees have high mental health needs. Syrian refugees do not seek mental health care despite availability of mental health services in the community.

The Influence of Perforated Prosthetic Liners on Residual Limb Wound Healing: a Case Report

CASE DESCRIPTION

Good residual limb skin health is vital to successful prosthetic prescription. Unnatural loading profiles and excessive sweating can lead to skin and soft tissue problems. Perforated liners allow the transport of moisture away from the skin and allow negative pressure (a condition that has been shown to aid wound healing) to act directly on the residuum surface.

AIM

Assess the effects of perforated prosthetic liner use, particularly with respect to wound healing.

METHOD

Three patient histories were retrospectively reviewed following prescription of perforated prosthetic liners due to excessive sweating or prolonged residual limb health concerns. Photographic records from patient files were used to document changes in residual limb condition. Patients also provided subjective feedback regarding their experiences.

FINDINGS

Two cases described active amputees with persistent blistering irritated during exercise. Another case described a patient of low mobility level with a history of residual limb skin infections. All saw their conditions heal and reported a reduction in problematic sweating. Two patients reported cancelling surgical interventions after substantial improvements with the perforated liner.

DISCUSSION

These findings provide evidence that the use of perforated prosthetic liners allow improvements in residual limb health, while still permitting prosthetic use.

Quality of reporting and fragility index for randomized controlled trials in the vesicoureteral reflux literature: where do we stand?

BACKGROUND/INTRODUCTION

Randomized controlled trials (RCTs) are considered the "gold standard" methodology for examining the effects of clinical interventions, yet only 1% of urology literature employs this design. The Consolidated Standards of Reporting Trials (CONSORT) statement contains a standardized checklist of 37 items to be included when reporting RCTs to ensure transparency and completeness of information [2]. Despite the robust design of RCTs, the number of events can greatly change the significance of the results, which can be represented by the fragility index (FI).

OBJECTIVE

The objective was to assess the quality of reporting of RCTs in the pediatric vesicoureteral reflux (VUR) literature using the 2010 CONSORT statement and, for studies with significant positive findings, to determine the FI as a measure of robustness of the results.

STUDY DESIGN

A comprehensive search was conducted through MEDLINE® and Embase® to identify RCTs in VUR literature from 2000 to 2016. Two reviewers independently selected articles, which were evaluated using the CONSORT checklist. An overall quality of reporting score (OQS) (%) was calculated by dividing the number of checklist items present in each study by the maximum possible score (34) and expressed as a percentage. Studies were classified as low (<40%), moderate (40-70%) and high quality (>70%) based on the modified assessing the methodological quality of systematic reviews (AMSTAR) checklist. Of the 2052 initial matches, 98% were excluded due to methodology or content, a further 28 studies were found not to meet inclusion criteria after full text review. The FI was calculated for the 7 studies that met inclusion criteria with significantly different results by manually adding events to the study groups until p>0.05.

RESULTS

Twenty-two studies met inclusion criteria. The mean OQS was 46+17% with 9 (41%) identified as low quality (score <40%), 11 (50%) as moderate (40-70%) and 2 (9%) as high quality (>70%). There was no significant difference in OQS between RCTs with a sample size > 100 (n=15) versus <100 patients (n=7) (45+17% vs. 47+17%, p=0.7). However, we noted a difference when we compared RCTs with biostatistician support (n=4) vs. those without (n=18) (59+20% vs. 43+15%, p<0.05). Seven studies reported significant positive results making calculation of FI possible. The mean FI was 5.8+5.1 indicating that most studies were fragile. There was no correlation between the OQS and FI.

DISCUSSION AND CONCLUSION

The mean OQS of VUR RCTs was suboptimal (46%), with most studies having low FI scores indicating the instability of the findings. The only variable that significantly impacted the OQS was biostatistician support. Implementation of the CONSORT checklist with a minimum of 50% inclusion as a prerequisite for submission of manuscripts may improve the quality and transparency of reporting. Calculation of the FI could provide readers with an objective measure of robustness for the published trials, allowing for appropriate interpretation of the results.

A pressure and shear sensor system for stress measurement at lower limb residuum/socket interface

A sensor system for measurement of pressure and shear at the lower limb residuum/socket interface is described. The system comprises of a flexible sensor unit and a data acquisition unit with wireless data transmission capability. Static and dynamic performance of the sensor system was characterised using a mechanical test machine. The static calibration results suggest that the developed sensor system presents high linearity (linearity error ≤ 3.8%) and resolution (0.9 kPa for pressure and 0.2 kPa for shear). Dynamic characterisation of the sensor system shows hysteresis error of approximately 15% for pressure and 8% for shear. Subsequently, a pilot amputee walking test was conducted. Three sensors were placed at the residuum/socket interface of a knee disarticulation amputee and simultaneous measurements were obtained during pilot amputee walking test. The pressure and shear peak values as well as their temporal profiles are presented and discussed. In particular, peak pressure and shear of approximately 58 kPa and 27 kPa, respectively, were recorded. Their temporal profiles also provide dynamic coupling information at this critical residuum/socket interface. These preliminary amputee test results suggest strong potential of the developed sensor system for exploitation as an assistive technology to facilitate socket design, socket fit and effective monitoring of lower limb residuum health.

Serine protease inhibitor-6 differentially affects the survival of effector and memory alloreactive CD8-T cells

The clonal expansion of effector T cells and subsequent generation of memory T cells are critical in determining the outcome of transplantation. While cytotoxic T lymphocytes induce direct cytolysis of target cells through secretion of Granzyme-B (GrB), they also express cytoplasmic serine protease inhibitor-6 (Spi6) to protect themselves from GrB that has leaked from granules. Here, we studied the role of GrB/Spi6 axis in determining clonal expansion of alloreactive CD8-T cells and subsequent generation of memory CD8-T cells in transplantation. CD8-T cells from Spi6(-/-) mice underwent more GrB mediated apoptosis upon alloantigen stimulation in vitro and in vivo following adoptive transfer into an allogeneic host. Interestingly, while OT1.Spi6(-/-) CD8 T cells showed significantly lower clonal expansion following skin transplants from OVA mice, there was no difference in the size of the effector memory CD8-T cells long after transplantation. Furthermore, lack of Spi6 resulted in a decrease of short-lived-effector-CD8-cells but did not impact the pool of memory-precursor-effector-CD8-cells. Similar results were found in heart transplant models. Our findings suggest that the final alloreactive CD8-memory-pool-size is independent from the initial clonal-proliferation as memory precursors express low levels of GrB and therefore are independent of Spi6 for survival. These data advance our understanding of memory T cells generation in transplantation and provide basis for Spi6 based strategies to target effector T cells.

An evaluation of a collaborative bibliotherapy scheme delivered via a library service

This paper reports on the evaluation of a bibliotherapy scheme delivered via a local library service, in conjunction with General Practice (GP) practices, local social welfare agencies and through self-referral. The Read Yourself Well (RYW) scheme was based on principles established from other similar schemes and as a way of delivering support for adults experiencing mild to moderate mental health problems for whom clinical treatments are not appropriate. The intervention consisted of initial referral and evaluation by the scheme bibliotherapist, a one-hour session at the beginning and end of the intervention where a purpose-designed questionnaire and two mental health assessments were carried out (the General Health Questionnaire and the Clinical Outcomes in Routine Evaluation questionnaire). Contact and support from the bibliotherapist was provided during the intervention period. One hundred and fifty-seven participants were recruited to the evaluation of whom 114 provided full data. Statistical analyses of the mental health scores showed significant improvements post treatment, for, both male and female participants, for all three referral routes, and for participants who were previously library users, and those who joined the library service to participate in the RYW scheme. The results of this large sample evaluation support the proposal that library-based bibliotherapy can be effective in the treatment of mental health problems.

Antitopoisomerase antibody positivity predates nailfold capillaroscopy abnormalities in scleroderma. Postulated classification of 'prescleroderma'

In a patient with early topoisomerase antibody-positive scleroderma, antinuclear antibody positivity was fortuitously observed to predate nailfold capillaroscopy changes. Using this case as a template, the prediagnostic phase of the presumed multifactorial disease may be divided into 5 temporal phases--phase 1 representing conception and intrauterine environment, phase 2 representing the extrauterine environment predating environmental exposure; phase 3 representing the early post-environmental exposure interval with no detectable perturbed body status; phase 4 representing the post-environmental exposure interval characterized by autoantibody production and microvascular changes, and phase 5, the symptomatic clinical prediagnostic interval (Raynaud's, skin, musculoskeletal, gastrointestinal, cardiorespiratory) prompting scleroderma diagnosis. Temporal classification of prescleroderma aids in both the understanding and definition of scleroderma 'onset'. If altered nailfold capillaries and autoantibodies develop at comparable rates, and if the findings from this case--that autoantibody changes precede microvascular changes--are truly representative of the preclinical disease phase, then these findings argue that the evolution of the disease is from within the vessel outwards, rather than vice versa.

Public health interventions and behaviour change: reviewing the grey literature

OBJECTIVES

This study identified and reviewed grey literature relating to factors facilitating and inhibiting effective interventions in three areas: the promotion of mental health and well-being, the improvement of food and nutrition, and interventions seeking to increase engagement in physical activity.

STUDY DESIGN

Sourcing, reviewing and analysis of relevant grey literature.

METHODS

Evidence was collected from a variety of non-traditional sources. Thirty-six pieces of documentary evidence across the three areas were selected for in-depth appraisal and review.

RESULTS

A variety of approaches, often short-term, were used both as interventions and outcome measures. Interventions tended to have common outcomes, enabling the identification of themes. These included improvements in participant well-being as well as identification of barriers to, and promoters of, success. Most interventions demonstrated some positive impact, although some did not. This was particularly the case for more objective measures of change, such as physiological measurements, particularly when used to evaluate short-term interventions. Objective health measurement as part of an intervention may act as a catalyst for future behaviour change. Time is an important factor that could either promote or impede the success of interventions for both participants and facilitators. Likewise, the importance of involving all stakeholders, including participants, when planning health promoting interventions was established as an important indicator of success.

DISCUSSION

Despite its limited scope, this review suggests that interventions can be more efficient and effective. For example, larger-scale, longer-term interventions could be more efficient, whilst outcomes relating to the implementation and beyond could provide a clearer picture of effectiveness. Additionally, interventions and evaluations must be flexible, evolve in partnership with local communities, and reflect local need and context.

Influence of housing type and age in female pigs. 2. Effects on biochemical indicators of fat metabolism and the fatty acid profile of belly fat and back fat depots

Weaning pigs into deep-litter (D) housing systems and then moving them into conventional (C) housing facilities affects the growth paths of the pigs and can result in differences in carcass composition which may be explained by altered fat metabolism. To examine this proposition experimentally, 160 female Large White × Landrace pigs were obtained at 3 weeks of age, average liveweight 5.5 ± 0.08 kg and were stratified by weight to four treatments. The treatments consisted of two housing treatments, C or D, across two growth periods: (i) early (3–13 weeks of age); and (ii) late (13–24 weeks of age). At ~13 weeks of age eight pigs per experimental treatment (n = 32) were slaughtered and the remaining pigs (n = 128) moved to new pens where they were housed until slaughter at ~24 weeks of age. To 13 weeks of age, the effect of housing type on lipogenesis did not reach significance (P > 0.05). At 24 weeks of age there were some treatment differences in fatty acid profile (P ≤ 0.05) and the concentration of plasma glycerol (P = 0.002) and non-esterified fatty acids (P = 0.019). There were trends for lipogenic enzyme activity to differ between treatments also (P < 0.100). Results suggested fat deposition was lower in D-finished pigs compared with C-finished pigs, rejecting the hypothesis that D-finished pigs would be fatter. However, most of the differences in the biochemical measurements were explained by the significant reduction in growth that occurred when pigs changed housing environments, rather than as an effect of the housing environment itself. Indicators of lipogenesis suggested that lipogenic rate was lowest in pigs moved from C to D housing compared with other treatment groups that had remained within the same housing, C or D, throughout the experiment or had moved from D housing to C housing at 13 weeks of age.

Natural Occurrence of Phytophthora infestans Causing Late Blight on Woody Nightshade (Solanum dulcamara) in New York

Woody nightshade (Solanum dulcamara) is a common hedgerow herbaceous perennial in the United States, one of only three native Solanum spp. S. dulcamara is a known host of Phytophthora infestans (3), but infection is rarely reported. There is a U.S. record from Maryland (2); in 1947, Peterson (4) stated that this species had never been found blighted in its natural habitat, although in 1960 it was listed as a host of P. infestans in New York (1). The A2 mating type has not been reported on this host. On 2 July, 2009, leaf lesions similar to those of P. infestans on potato were found on wild S. dulcamara at Riverhead, NY. The plant was growing in a home garden within 10 m of potato and tomato plants infected with P. infestans. When two infected leaves of S. dulcamara were incubated for 24 h under high humidity, a pathogen growth developed around the lesion margins that was characterized by hyaline mycelium bearing lemon-shaped sporangia that released motile zoospores after chilling in water, which is consistent with P. infestans. The caducous and limoniform to ovoid sporangia were 39 to 50 μm (average 45 μm) × 26 to 28 μm (average 27 μm) with a length/breadth ratio of 1.66. No oospores were observed. Three isolates were obtained from this plant during July 2009. Growth on rye agar was indistinguishable from that of local tomato isolates of P. infestans. Detached leaflets of S. dulcamara and S. tuberosum, inoculated with the woody nightshade isolates and kept in a humid chamber, became infected and developed profuse sporulation within 5 days. The pathogen isolated was confirmed as P. infestans by morphological, biochemical, and molecular characteristics. Inoculations of attached leaves of potted S. dulcamara plants resulted in necrotic lesions with many sporangia; sporulation also developed on inoculated, attached, and detached tomato leaves. P. infestans was reisolated and identity confirmed as before. The three isolates were A2 mating type, metalaxyl-resistant, mitochondrial haplotype Ia. All were glucose-6-phosphate isomerase 100/122 and peptidase 100/100, as confirmed with single-spore isolates. RG57 fingerprint analysis confirmed that isolates from woody nightshade, tomato, and potato obtained from the same and nearby sites were identical. Although P. infestans in the United States belongs to the new population, which may infect a wider host range than the old US-1 clonal lineage, S. dulcamara infections have only been found when late blight is already widespread in neighboring fields and there is no evidence to suggest that woody nightshade acts as an overwintering host in the United States. References: (1) Anonymous. Index of Plant Diseases in the United States. Page 456 in: Agric. Handb. No. 165, 1960 (2) C. Cox. Phytopathology 38:575, 1948. (3) D. C. Erwin and O. K. Ribeiro. Page 190 in: Phytophthora Diseases Worldwide. The American Phytopathological Society, St. Paul, MN, 1996. (4) L. C. Peterson. Am. Potato J. 24:188, 1947.

Hypovitaminosis D among healthy adolescent girls attending an inner city school

AIMS

To determine the prevalence of hypovitaminosis D among healthy adolescent schoolgirls attending an inner city multiethnic girls' school.

METHODS

Fifty one (28%) of 182 girls (14 white, 37 non-white; median age 15.3 years, range 14.7-16.6) took part in the study. Biochemical parameters, dietary vitamin D intake, muscle function parameters, duration of daily sunlight exposure (SE), and percentage of body surface area exposed (%BSA) were measured.

RESULTS

Thirty seven (73%) girls were vitamin D deficient (25-hydroxyvitamin D (25OHD) <30 nmol/l) and 9 (17%) were severely deficient (25OHD <12.5 nmol/l). The median (range) 25OHD concentration of white girls (37.3 nmol/l (18.3-73.3)) was higher than that of non-white girls (14.8 nmol/l (5.8-42.8)). The median (range) concentration of parathyroid hormone in white girls (2.8 pmol/l (1.0-3.7)) was lower than that of non-white girls (3.4 pmol/l (1.7-34.2)). Serum Ca, inorganic phosphate, alkaline phosphatase, and 1,25-dihydroxyvitamin D were not different in white and non-white girls. For the whole group, 25OHD concentration was related to the estimated SE and %BSA, but not to estimated intake of vitamin D. In white girls, the estimated SE and %BSA were significantly higher than that of non-white girls. The median times taken to complete the Gower's manoeuvre and grip strength were not different in the two groups; these variables were not related to serum 25OHD.

CONCLUSIONS

Hypovitaminosis D is common among healthy adolescent girls; non-white girls are more severely deficient. Reduced sunshine exposure rather than diet explains the difference in vitamin D status of white and non-white girls.

Chemical phosphorus removal to extremely low levels: experience of two plants in the Washington, DC area

Chemical phosphorus removal using metal (iron and aluminium) salts is frequently used to control effluent soluble phosphorus levels in wastewater treatment plants. In the Washington DC area effluent phosphorus requirements are extremely stringent to protect the Chesapeake Bay. Full-scale data from two plants in the area were analysed to establish phosphate behaviour in the presence of iron. Titration experiments and mathematical modelling were performed to determine the role of ferric phosphate and hydroxide precipitation and other mechanisms that may potentially be involved in phosphorus removal. Iron addition is described in the model using a chemical equilibrium approach extended with surface charges and adsorption. The model verifies key observations from full-scale data: (a) extremely low orthophosphate levels can be achieved over a wide range of pH values, (b) a mixture of ferric phosphate and ferric hydroxide precipitate is forming with the hydroxide acting as sorbent, (c) molar ratios of Fe/P (iron dosed to phosphate removed) vary widely (1.0-3.9) based on the technology used and residual phosphate levels. The model will be a useful tool for engineers to optimise preliminary, simultaneous and tertiary P removal, both for design and plant operation.

Effects of lesions of the human posterior thalamus on ocular fixation during voluntary and visually triggered saccades

OBJECTIVE

To investigate the role of the posterior thalamus in controlling voluntary and visually triggered eye movements and ocular fixation.

METHODS

The latency to initiate saccades to peripheral targets (visually triggered) and in response to verbal commands (voluntary) was measured in three patients with unilateral lesions of the posterior thalamus, in normal controls, and in neurological controls with Parkinson's disease. On half the trials a fixation point offset simultaneously with target onset, and on half it remained visible.

RESULTS

Offset of the fixation point simultaneous with target onset decreased saccade latency for both voluntary and visually triggered eye movements in controls, but only for voluntary saccades in patients with thalamic lesions.

CONCLUSIONS

These findings suggest that separate neural systems control fixation when making voluntary and visually triggered eye movements, and that the thalamus is involved in the control of fixation for visually triggered but not for voluntary saccades.

Effects of a vertical magnetic field on particle confinement in a magnetized plasma torus

The particle confinement in a magnetized plasma torus with superimposed vertical magnetic field is modeled and measured experimentally. The formation of an equilibrium characterized by a parallel plasma current canceling out the grad B and curvature drifts is described using a two-fluid model. Characteristic response frequencies and relaxation rates are calculated. The predictions for the particle confinement time as a function of the vertical magnetic field are verified in a systematic experimental study on the TORPEX device, including the existence of an optimal vertical field and the anticorrelation between confinement time and density.

Aortopulmonary size discrepancy is not a contraindication to the pediatric Ross operation

BACKGROUND

Modification of the aortic annulus or the ascending aorta, or both, may be required in pediatric patients undergoing the Ross operation. The fate of these autografts remains uncertain.

METHODS

Retrospective review of 15 patients undergoing Ross operation without aortic annular modification (group 1), 11 patients requiring annular reduction (group 2, n = 11), and 8 patients requiring annular enlargement (group 3, n = 8). Autograft function and dimensions were evaluated by echocardiography.

RESULTS

Autograft insufficiency was less than or equal to mild in 33 patients and moderate in 1 patient. The annulus body surface area ratio increased in group 1 from 19.7 +/- 5 to 20.3 +/- 5 mm/M2 (p = 0.8). The average annular reduction in group 2 was 5 +/- 1.5 mm, and 10 of 11 patients required reduction of the ascending aorta (mean 11 +/- 5 mm). The annulus body surface area ratio increased from 18.6 +/- 7 to 20.5 +/- 9 mm/M2 (p = 0.2). The mean augmentation in annulus diameter in group 3 was 6 +/- 4 mm; the annulus body surface area ratio decreased from 23.7 +/- 14 to 20.3 +/- 8 mm/M2 (p = 0.5).

CONCLUSIONS

We continue to offer the Ross operation to pediatric patients even when aortic annular or ascending aortic size discrepancies mandate surgical modifications.

Evaluation of the prognosis of in vitro fertilization pregnancies with initially low serum human chorionic gonadotropin levels

OBJECTIVE

The objective of this study was to investigate the prognostic significance of initially low serum early human chorionic gonadotropin levels in in vitro fertilization pregnancies that progress to an intrauterine gestational sac.

STUDY DESIGN

This retrospective cohort study compared 65 in vitro fertilization pregnancies with an initial human chorionic gonadotropin value at 4 weeks of < or =20 mIU/mL with 130 pregnancies with human chorionic gonadotropin values >20 mIU/mL. All pregnancies had a singleton intrauterine sac at 6 weeks' gestational age. Spontaneous abortion rates and pregnancy complications were compared.

RESULTS

Women with a low initial serum human chorionic gonadotropin level showed a statistically significant increase in first-trimester pregnancy loss (36.5% vs 9.2%; odds ratio, 5.7; 95%; confidence interval, 2.6, 12.4; P <.0001). Once pregnancies progressed to 13 weeks, there were no significant differences.

CONCLUSIONS

In vitro fertilization pregnancies with a low initial human chorionic gonadotropin value, despite progressing to a gestational sac, are at an increased risk of spontaneous abortion.

Review of policies and guidelines on infant feeding in emergencies: common ground and gaps

Recent crises in regions where exclusive breastfeeding is not the norm have highlighted the importance of effective policies and guidelines on infant feeding in emergencies. In 1993, UNICEF compiled a collection of policy and guideline documents relating to the feeding of infants in emergency situations. In June 2000 Save the Children, UK, UNICEF and the Institute of Child Health undertook a review of those documents, updating the list and identifying the common ground that exists among the different policies. The review also analysed the consistency of the policy framework, and highlighted important areas where guidelines are missing or unclear. This article is an attempt to share more widely the main issues arising from this review. The key conclusions were that, in general, there is consensus on what constitutes best practice in infant feeding, however, the lack of clarity in the respective responsibilities of key UN agencies (in particular UNICEF, UNHCR and WFP) over issues relating to co-ordination of activities which affect infant-feeding interventions constrains the implementation of systems to support best practice. Furthermore, the weak evidence base on effective and appropriate intervention strategies for supporting optimal infant feeding in emergencies means that there is poor understanding of the practical tasks needed to support mothers and minimise infant morbidity and mortality. We, therefore, have two key recommendations: first that the operational UN agencies, primarily UNICEF, examine the options for improving co-ordination on a range of activities to uphold best practice of infant feeding in emergencies; second, that urgent attention be given to developing and supporting operational research on the promotion of optimal infant-feeding interventions.

From policy to practice: challenges in infant feeding in emergencies during the Balkan crisis

The preparation and dissemination of policy statements are necessary but insufficient to prevent the inappropriate use of infant-feeding products in emergencies. The widespread failure of humanitarian agencies operating in the Balkan crisis to act in accordance with international policies and recommendations provides a recent example of the failure to translate infant-feeding policies into practice. This article explores the underlying reasons behind the failures which include: (1) the weak institutionalisation of policies; (2) the massive quantities of unsolicited donations of infant-feeding products: (3) the absence of monitoring systems; (4) inadequate co-ordination mechanisms; (5) the high costs of correcting mistakes; and (6) the cumulative effects of poor practice. Efforts to uphold best practice during the crisis are also documented. Finally, the article identifies actions that could be undertaken in advance of and during future emergencies to enhance the application of infant feeding policies in emergencies.