The risk of complaints against occupational physicians to the medical regulatory body in Ireland

Complaints against doctors to regulators are increasing in all jurisdictions. Occupational physicians (OPs) are at increased risk of complaint due to the unique doctor–patient relationship and the dual obligations of the role. OPs may become embroiled in third-party disputes and must be clear that their role is an advisor to the decision-maker, but not the decision-maker. OPs require training in how to reduce, cope with and defend against complaints to regulators.

COVID-19 vaccination uptake and hesitancy reasons in food production workers

BACKGROUND

Food production sites have been a high-risk location for SARS-CoV-2 outbreaks worldwide since early in the COVID-19 pandemic. Ireland has a high population rate of COVID-19 vaccination, but reports from food production sites suggest uptake is lower amongst workers despite prior outbreaks at these workplaces.

AIMS

To study COVID-19 vaccination rates, intent to undertake future vaccination and hesitancy reasons in food production workers.

METHODS

Data regarding vaccination status was collected via an online survey from workers at 8 food production sites in Ireland; those who were unvaccinated were asked for reasons for being unvaccinated and likelihood to future vaccination. Respondents were also asked for their usual trusted source of medical information.

RESULTS

N = 355 responses were received. The crude vaccination rate is 86% (N = 306). Those employed in the general operative class are more likely to be unvaccinated (N = 30; 18%) when compared to unvaccinated in all other job classes (N = 16; 9%: p < 0.01). The rate of vaccination is lower in those not born in Ireland compared to those born in Ireland (N = 110, 73% vs N = 192; 98%: p < 0.001). N = 35 (76%) of unvaccinated workers report they are very unlikely or unlikely to undertake vaccination in the future.

CONCLUSIONS

There is an observed lower-than-national vaccination rate in food production workers. Rates are lowest amongst those workers born overseas; targeting these groups with information responding to their concerns may increase uptake and reduce current and future health inequalities.

Eruptive keratoacanthomas associated with dupilumab therapy

We would like to present the case of eruptive keratoacanthomas associated with dupilumab therapy, which occurred in an 85-year-old woman receiving biologic therapy for the treatment of atopic dermatitis. With the increasing prevalence of Dupilumab usage, this is an important potential complication of which clinicians should be aware.

The lead up to tobacco plain packaging policy in Turkey

Background

Research shows tobacco plain packaging (TPP) is effective in reducing the attractiveness of tobacco products, effectiveness of tobacco packaging and increases the impact of health warnings. Since Australia introduced TPP in 2012, several other countries have adopted similar legislation, and more have begun preparations for introducing it. Turkey first announced its intention to proceed with TPP in 2011, however prior to the eventual passage of legislation in December 2018 there were many false starts and delays. This study (conducted in 2018 before TPP legislation was passed in Turkey) explored the barriers and facilitators to introducing legislation.

Methods

A qualitative study design was employed using a single case study approach. Publicly available documents relevant to TPP in Turkey were analysed and interviews with key informants from academics, bureaucrats in government ministries and non-government organisations (NGOs) were conducted in 2018.

Results

Barriers such as changes to the government, tobacco industry opposition and the economic crisis appeared to contribute most to the delays in introducing TPP. Despite the barriers Turkey had faced, TPP legislation managed to reach the political agenda primarily through the collaborative advocacy efforts of NGOs, academics and the leadership of particular tobacco control advocates.

Conclusions

TPP legislation was approved by the Turkish government on the 5th December 2018 and has been in force since the 5th January 2020. Implications for the wider uptake of TPP include the importance of building effective coalitions and raising public awareness.

Key messages

The tobacco industry opposition can be defeated by tobacco control advocates working together. Turkey’s experience should be considered by other countries who are willing to implement TPP.

Root microbiomes as indicators of seagrass health

The development of early warning indicators that identify ecosystem stress is a priority for improving ecosystem management. As microbial communities respond rapidly to environmental disturbance, monitoring their composition could prove one such early indicator of environmental stress. We combined 16S rRNA gene sequencing of the seagrass root microbiome of Halophila ovalis with seagrass health metrics (biomass, productivity and Fsulphide) to develop microbial indicators for seagrass condition across the Swan-Canning Estuary and the Leschenault Estuary (south-west Western Australia); the former had experienced an unseasonal rainfall event leading to declines in seagrass health. Microbial indicators detected sites of potential stress that other seagrass health metrics failed to detect. Genera that were more abundant in 'healthy' seagrasses included putative methylotrophic bacteria (e.g. Methylotenera and Methylophaga), iron cycling bacteria (e.g. Deferrisoma and Geothermobacter) and N2 fixing bacteria (e.g. Rhizobium). Conversely, genera that were more abundant in 'stressed' seagrasses were dominated by putative sulphur-cycling bacteria, both sulphide-oxidising (e.g. Candidatus Thiodiazotropha and Candidatus Electrothrix) and sulphate-reducing (e.g. SEEP-SRB1, Desulfomonile and Desulfonema). The sensitivity of the microbial indicators developed here highlights their potential to be further developed for use in adaptive seagrass management, and emphasises their capacity to be effective early warning indicators of stress.

Soil Salinity and pH Drive Soil Bacterial Community Composition and Diversity Along a Lateritic Slope in the Avon River Critical Zone Observatory, Western Australia

Soils are crucial in regulating ecosystem processes, such as nutrient cycling, and supporting plant growth. To a large extent, these functions are carried out by highly diverse and dynamic soil microbiomes that are in turn governed by numerous environmental factors including weathering profile and vegetation. In this study, we investigate geophysical and vegetation effects on the microbial communities of iron-rich lateritic soils in the highly weathered landscapes of Western Australia (WA). The study site was a lateritic hillslope in southwestern Australia, where gradual erosion of the duricrust has resulted in the exposure of the different weathering zones. High-throughput amplicon sequencing of the 16S rRNA gene was used to investigate soil bacterial community diversity, composition and functioning. We predicted that shifts in the microbial community would reflect variations in certain edaphic properties associated with the different layers of the lateritic profile and vegetation cover. Our results supported this hypothesis, with electrical conductivity, pH and clay content having the strongest correlation with beta diversity, and many of the differentially abundant taxa belonging to the phyla Actinobacteria and Proteobacteria. Soil water repellence, which is associated with Eucalyptus vegetation, also affected beta diversity. This enhanced understanding of the natural system could help to improve future crop management in WA since the physicochemical properties of the agricultural soils in this region are inherited from laterites via the weathering and pedogenesis processes.

Low Light Availability Alters Root Exudation and Reduces Putative Beneficial Microorganisms in Seagrass Roots

Seagrass roots host a diverse microbiome that is critical for plant growth and health. Composition of microbial communities can be regulated in part by root exudates, but the specifics of these interactions in seagrass rhizospheres are still largely unknown. As light availability controls primary productivity, reduced light may impact root exudation and consequently the composition of the root microbiome. Hence, we analyzed the influence of light availability on root exudation and community structure of the root microbiome of three co-occurring seagrass species, Halophila ovalis, Halodule uninervis and Cymodocea serrulata. Plants were grown under four light treatments in mesocosms for 2 weeks; control (100% surface irradiance (SI), medium (40% SI), low (20% SI) and fluctuating light (10 days 20% and 4 days 100%). 16S rDNA amplicon sequencing revealed that microbial diversity, composition and predicted function were strongly influenced by the presence of seagrass roots, such that root microbiomes were unique to each seagrass species. Reduced light availability altered seagrass root exudation, as characterized using fluorescence spectroscopy, and altered the composition of seagrass root microbiomes with a reduction in abundance of potentially beneficial microorganisms. Overall, this study highlights the potential for above-ground light reduction to invoke a cascade of changes from alterations in root exudation to a reduction in putative beneficial microorganisms and, ultimately, confirms the importance of the seagrass root environment - a critical, but often overlooked space.

Expert clinical management of autoimmune hepatitis in the real world

BACKGROUND

High-quality data on the management of autoimmune hepatitis (AIH) are scarce. Despite published guidelines, management of AIH is still expert based rather than evidence based.

AIM

To survey expert hepatologists, asking each to describe their practices in the management of patients with AIH.

METHODS

A survey questionnaire was distributed to members of the International AIH Group. The questionnaire consisted of four clinical scenarios on different presentations of AIH.

RESULTS

Sixty surveys were sent, out of which 37 were returned. None reported budesonide as a first line induction agent for the acute presentation of AIH. Five (14%) participants reported using thiopurine S-methyltransferase measurements before commencement of thiopurine maintenance therapy. Thirteen (35%) routinely perform liver biopsy at 2 years of biochemical remission. If histological inflammatory activity is absent, four (11%) participants reduced azathioprine, whereas 10 (27%) attempted withdrawal altogether. Regarding the management of difficult-to-treat patients, mycophenolate mofetil is the most widely used second-line agent (n = ~450 in 28 centres), whereas tacrolimus (n = ~115 in 21 centres) and ciclosporin (n = ~112 in 18 centres) are less often reported. One centre reported considerable experience with infliximab, while rescue therapy with rituximab has been tried in seven centres.

CONCLUSIONS

There is a wide variation in the management of patients with autoimmune hepatitis even among the most expert in the field. Although good quality evidence is lacking, there is considerable experience with second-line therapies. Future prospective studies should address these issues, so that we move from an expert- to an evidence- and personalised-based care in autoimmune hepatitis.

The effect of storage conditions on the composition and functional properties of blended bulk tank milk

The objective of this study was to investigate the effects of storage temperature and duration on the composition and functional properties of bulk tank milk when fresh milk was added to the bulk tank twice daily. The bulk tank milk temperature was set at each of 3 temperatures (2, 4, and 6°C) in each of 3 tanks on 2 occasions during two 6-wk periods. Period 1 was undertaken in August and September when all cows were in mid lactation, and period 2 was undertaken in October and November when all cows were in late lactation. Bulk tank milk stored at the 3 temperatures was sampled at 24-h intervals during storage periods of 0 to 96 h. Compositional parameters were measured for all bulk tank milk samples, including gross composition and quantification of nitrogen compounds, casein fractions, free amino acids, and Ca and P contents. The somatic cell count, heat stability, titratable acidity, and rennetability of bulk tank milk samples were also assessed. Almost all parameters differed between mid and late lactation; however, the interaction between lactation, storage temperature, and storage duration was significant for only 3 parameters: protein content and concentrations of free cysteic acid and free glutamic acid. The interaction between storage temperature and storage time was not significant for any parameter measured, and temperature had no effect on any parameter except lysine: lysine content was higher at 6°C than at 2°C. During 96 h of storage, the concentrations of some free amino acids (glutamic acid, lysine, and arginine) increased, which may indicate proteolytic activity during storage. Between 0 and 96 h, minimal deterioration was observed in functional properties (rennet coagulation time, curd firmness, and heat stability), which was most likely due to the dissociation of β-casein from the casein micelle, which can be reversed upon pasteurization. Thus, this study suggests that blended milk can be stored for up to 96 h at temperatures between 2°C and 6°C with little effect on its composition or functional properties.

Environmental drivers of soil microbial community structure and function at the Avon River Critical Zone Observatory

The Critical Zone is defined as the thin, permeable layer from the tops of the trees to the bottom of the bedrock that sustains terrestrial life on Earth. The geometry and shape of the various weathering zones are known as the critical zone architecture. At the centre of the Critical Zone are soils and the microorganisms that inhabit them. In Western Australia, the million-year-old stable weathering history and more recent lateral erosion during the past hundreds of thousands of years have created a geomorphic setting where deep weathering zones are now exposed on the surface along the flanks of many lateritic hills. These old weathering zones provide diverse physical and chemical properties that influence near surface pedologic conditions and thus likely shape current surface microbiology. Here, we present data derived from a small lateritic hill on the UWA Farm Ridgefield. Spatial soil sampling revealed the contrasting distribution patterns of simple soil parameters such as pH (CaCl2) and electric conductivity. These are clearly linked with underlying changes of the critical zone architecture and show a strong contrast with low values of pH3.3 at the top of the hill to pH5.3 at the bottom. These parameters were identified as major drivers of microbial spatial variability in terms of bacterial and archaeal community composition but not abundance. In addition, we used sensitive (14)C labelling to assess turnover of three model organic nitrogen compounds - an important biogeochemical functional trait relating to nutrient availability. Though generally rapid and in the order of rates reported elsewhere (t½<5h), some points in the sampling area showed greatly reduced turnover rates (t½>10h). In conclusion, we have shown that the weathering and erosion history of ancient Western Australia affects the surface pedology and has consequences for microbial community structure and function.

Seasonal trends in milk quality in Ireland between 2007 and 2011

The objectives of this study were to evaluate annual and seasonal trends in bulk tank somatic cell count (SCC), total bacterial count (TBC), and laboratory pasteurization count (LPC) in Ireland between 2007 and 2011 (inclusive), and to compare trends based on herd type and herd size. The unadjusted median SCC and TBC of all records were 266,000 and 17,000 cfu/mL, respectively. Data were transformed to log values and analyzed using a mixed model. Fixed effects included milk processor, year, month, and total monthly milk volume; milk producer was fitted as a random variable. After analysis, means were back transformed for interpretation. Annual SCC increased slightly from 259,000 cells/mL in 2007 to a peak of 272,647 cells/mL in 2009 and then declined slightly thereafter. Although statistically significant changes in annual TBC are probably not biologically relevant, values ranged between 23,922 and 26,290 cfu/mL. Annual LPC peaked in 2008 (265 cfu/mL), declined in 2009, and increased thereafter. Monthly mean SCC of all records increased from April onward, with the greatest increases seen from October to December, when the majority of cows entered late lactation. Monthly mean TBC exhibited a seasonal trend, whereby TBC was greatest at the beginning and end of the year, coinciding with winter housing. Seasonal milk production herds (n=8,002 herds) calve all cows in spring (February to April), whereas split-calving herds (n=1,829 herds) calve cows in the spring and autumn. From February to September, monthly SCC was lower for seasonal herds than for split-calving herds, whereas SCC was lower for split-calving herds for the remaining months. During winter (October to March), split-calving herds had lower monthly TBC than seasonal herds, most likely because of stricter regulations imposed upon them. Herd size was approximated using total annual milk production figures. Across all months, larger herds had lower SCC and TBC compared with smaller herds. No obvious improvements in milk quality were seen between 2007 and 2011. Farmers have the opportunity to improve milk quality by reducing bulk tank SCC in late lactation and by imposing stricter hygiene practices at the beginning and end of the year to overcome the seasonal variation of bulk tank TBC.

Microbialite taphonomy and biogenicity: new insights from NanoSIMS

We here show that nano-scale mapping of elements commonly utilized in biological cycles provides a promising new additional line of evidence when evaluating the extent of the contribution of biology to microbialites. Our case study comes from Lake Clifton in Western Australia, a unique environment where living domical and conical microbialites occur in close proximity to ≤ 4000-year-old fossilized equivalents. The outer margins of a partially lithified, actively growing Lake Clifton microbialite are characterized by abundant filamentous cyanobacteria within a loosely cemented aragonite matrix. Nano-scale chemical maps have been successfully matched to specific morphological features such as trichomes, sheaths and putative extracellular polymeric substances (EPS). A suite of elements (C, O, Mg, N, Si, S) is concentrated within cyanobacterial sheaths, with carbon, magnesium, nitrogen and sulfur also enriched within trichomes and putative EPS. Calcium distribution highlights the sites of aragonite mineralization. In contrast, the fossilized Lake Clifton microbialite contains only rare, extensively degraded cyanobacterial filaments, the mean diameter of which is <50% of the living equivalents. Nevertheless, nano-scale chemical maps can again be matched with morphological features. Here, poorly preserved filamentous microfossils are highlighted by enrichments in nitrogen and sulfur. Magnesium is no longer concentrated within the filaments, instead it co-occurs with calcium and oxygen in the calcite cement. Extension of this study to a ~2720-million-year-old stromatolitic microbialite from the Tumbiana Formation of Western Australia shows that similar nano-scale signals, in particular nitrogen and sulfur enrichments, are characteristic of stromatolite laminations, even when morphological microfossils are absent. The close similarities of nano-scale elemental distributions in organic material from modern and ancient microbialites show that this technique provides a valuable addition to the morphological investigation of such structures, particularly in non-fossiliferous ancient examples.

Effect of pre-milking teat preparation procedures on the microbial count on teats prior to cluster application

A study was carried out to investigate the effect of six pre-milking teat preparation procedures on lowering the staphylococal, streptococcal and coliform microbial count on teat skin prior to cluster application. The teat preparations included 'Iodine', 'Chlorhexidine' teat foam, 'Washing and drying' with paper, 'No preparation', 'Chlorine' teat foam, and disinfectant 'Wipes'. Teat preparations were applied for five days to 10 cows for each treatment during two herd management periods (indoors and outdoors). Teats were swabbed on day four and five before teat preparation and repeated after teat preparation. The swabs were plated on three selective agars: Baird Parker (Staphylococcus spp.), Edwards (Streptococcus spp.), and MacConkey (coliform). Following incubation, microbial counts for each pathogen type were manually counted and assigned to one of six categories depending on the microbial counts measured. The results were analysed by logistic regression using SAS 28. The main analysis was conducted on binary improvement scores for the swabbing outcomes. There were no differences for staphylococcal, streptococcal and coliform bacterial counts between treatments, measured 'before' teat preparation. Treatments containing 'Chlorhexidine' teat foam (OR = 4.46) and 'Wipes' (OR = 4.46) resulted in a significant reduction (P < 0.01) in the staphylococcal count on teats compared to 'Washing and drying' or 'No preparation'. 'Chlorine' teat foam (OR = 3.45) and 'Wipes' (3.45) had the highest probability (P < 0.01) of reducing streptococcal counts compared to 'Washing and drying' or 'No preparation'. There was no statistical difference between any of the disinfectant treatments applied in reducing coliforms. Thus, the use of some disinfectant products for pre-milking teat preparation can have beneficial effects on reducing the levels of staphylococcal and streptococcal pathogens on teat skin.

Effect of Sheep Urine Deposition on the Bacterial Community Structure in an Acidic Upland Grassland Soil

The effect of the addition of synthetic sheep urine (SSU) and plant species on the bacterial community composition of upland acidic grasslands was studied using a microcosm approach. Low, medium, and high concentrations of SSU were applied to pots containing plant species typical of both unimproved ( Agrostis capillaris ) and agriculturally improved ( Lolium perenne ) grasslands, and harvests were carried out 10 days and 50 days after the addition of SSU. SSU application significantly increased both soil pH ( P < 0.005), with pH values ranging from pH 5.4 (zero SSU) to pH 6.4 (high SSU), and microbial activity ( P < 0.005), with treatment with medium and high levels of SSU displaying significantly higher microbial activity (triphenylformazan dehydrogenase activity) than treatment of soil with zero or low concentrations of SSU. Microbial biomass, however, was not significantly altered by any of the SSU applications. Plant species alone had no effect on microbial biomass or activity. Bacterial community structure was profiled using bacterial automated ribosomal intergenic spacer analysis. Multidimensional scaling plots indicated that applications of high concentrations of SSU significantly altered the bacterial community composition in the presence of plant species but at different times: 10 days after application of high concentrations of SSU, the bacterial community composition of L. perenne -planted soils differed significantly from those of any other soils, whereas in the case of A. capillaris -planted soils, the bacterial community composition was different 50 days after treatment with high concentrations of SSU. Canonical correspondence analysis also highlighted the importance of interactions between SSU addition, plant species, and time in the bacterial community structure. This study has shown that the response of plants and bacterial communities to sheep urine deposition in grasslands is dependent on both the grass species present and the concentration of SSU applied, which may have important ecological consequences for agricultural grasslands.

Structural diversity of bacterial communities in a heavy metal mineralized granite outcrop

This laboratory study of a variably mineralized and hydrothermally altered granite outcrop investigated the influences of rock-surface chemistry and heavy metal content on resident bacterial populations. Results indicated that elevated heavy metal concentrations had a profound impact on bacterial community structure, with strong relationships found between certain ribotypes and particular chemical/heavy metal elements. Automated ribosomal intergenic sequence analysis (ARISA) was used to assess the nature and extent of bacterial diversity, and this was combined with chemical analysis and multivariate statistics to identify the main geochemical factors influencing bacterial community structure. A randomization test revealed significant changes in bacterial structure between samples, while canonical correspondence analysis (CCA) related each individual ARISA profile to linear combinations of the chemical variables (mineralogy, major element and heavy metal concentrations) revealing the geochemical factors that correlated with changes in the ARISA data. anova was performed to further explore interactions between individual ribotypes and chemical/heavy metal composition, and revealed that a high proportion of ribotypes correlated significantly with heavy metals.

Cannabinoid receptors in invertebrates

Two cannabinoid receptors, CB1 and CB2, are expressed in mammals, birds, reptiles, and fish. The presence of cannabinoid receptors in invertebrates has been controversial, due to conflicting evidence. We conducted a systematic review of the literature, using expanded search parameters. Evidence presented in the literature varied in validity, ranging from crude in vivo behavioural assays to robust in silico ortholog discovery. No research existed for several clades of invertebrates; we therefore tested for cannabinoid receptors in seven representative species, using tritiated ligand binding assays with [3H]CP55,940 displaced by the CB1-selective antagonist SR141716A. Specific binding of [3H]CP55,940 was found in neural membranes of Ciona intestinalis (Deuterstoma, a positive control), Lumbricusterrestris (Lophotrochozoa), and three ecdysozoans: Peripatoides novae-zealandiae (Onychophora), Jasus edwardi (Crustacea) and Panagrellus redivivus (Nematoda); the potency of displacement by SR141716A was comparable to measurements on rat cerebellum. No specific binding was observed in Actinothoe albocincta (Cnidaria) or Tethya aurantium (Porifera). The phylogenetic distribution of cannabinoid receptors may address taxonomic questions; previous studies suggested that the loss of CB1 was a synapomorphy shared by ecdysozoans. Our discovery of cannabinoid receptors in some nematodes, onychophorans, and crustaceans does not contradict the Ecdysozoa hypothesis, but gives it no support. We hypothesize that cannabinoid receptors evolved in the last common ancestor of bilaterians, with secondary loss occurring in insects and other clades. Conflicting data regarding Cnidarians precludes hypotheses regarding the last common ancestor of eumetazoans. No cannabinoid receptors are expressed in sponges, which probably diverged before the origin of the eumetazoan ancestor.

Ultrasound guidance in the placement of a percutaneous endoscopic gastrostomy (PEG): an adjuvant technique in patients with abdominal wall varices?

Malnutrition in patients with liver disease is common. As a result, enteral feeding may be indicated. Percutaneous endoscopic gastrostomy insertion is rarely performed because the presence of varices is considered to be a contraindication. We report a case of percutaneous endoscopic gastrostomy insertion in a patient with both gastric and oesophageal varices. The use of abdominal ultrasound may provide an adjuvant tool for percutaneous endoscopic gastrostomy insertion. This novel technique may minimise the risk of complications in selected patients.

Ill-health retirement among healthcare workers in the Southern Health Board of the Republic of Ireland

AIM

To determine the incidence rates, trends and medical causes of ill-health retirement (IHR) among different occupational classes in the Southern Health Board (SHB).

METHODS

The 14 702 permanent employees of the SHB were divided into six occupational classes based on socio-economic status and occupational demands. The occupational classes were compared for incidence rates of IHR, age at IHR, years of service and medical causes of IHR. The total group of employees was used as the standard for statistical comparison. Incidence rates were compared using standardized IHR ratios (SIHRRs). Medical causes were compared using proportional ill-health retirement ratios (PIHRRs).

RESULTS

Three hundred and three employees were granted IHR from 1994 to 2000. The overall incidence rate of IHR was 2.9 per 1000 employees per annum. The highest SIHRRs occurred in male maintenance staff at 345 (CI: 221-513) and female support staff at 158 (CI: 123-201). With regard to age and years of service, IHR peaked at a time that coincided with enhancement to pension entitlements. The common causes of IHR were musculoskeletal disorder (38%), mental illness(17%), circulatory disorder (12%) and neoplasia (8%). PIHRRs did not vary significantly between the classes.

CONCLUSION

IHR was more common among manual healthcare workers. The structure of the pension scheme appeared to influence the timing of IHR. Occupational class did not appear to influence the medical causes of IHR.

Detection of serum M2 anti-mitochondrial antibodies by enzyme-linked immunosorbent assay is potentially less specific than by immunofluorescence

AIM

To compare the predictive values of enzyme-linked immunosorbent assays (ELISAs) and indirect immunofluorescence (IIF) techniques for the detection of M2 anti-mitochondrial antibodies.

METHODS

Commercial ELISAs are widely available for the detection of anti-mitochondrial antibody subtypes in primary biliary cirrhosis (PBC). We compared the results from two ELISAs (one recombinant, one purified antigen) with those from two IIF methods in a well-defined cohort of PBC patients and in patients with systemic lupus erythematosus, Sjögren's syndrome, sicca syndrome, systemic sclerosis, rheumatoid arthritis and blood donor controls.

RESULTS

There was good correlation between a rodent substrate IIF and ELISA A (r=0.9134), but poor correlation with ELISA B (r=0.5999), which produced many false-positive results in the control population. We show that rodent IIF alone or human epithelial cell (HEp-2000) screening with confirmation by ELISA produce similar predictive values for PBC and require lesser degrees of skilled interpretation of IIF patterns.

CONCLUSIONS

We conclude that the specificities of IIF are greater than the ELISA methods (99% versus 85-97%), although the ELISAs are slightly more sensitive in biopsy-proven PBC. Careful in-house validation of all new ELISA technologies is mandatory for good laboratory practice, but IIF in experienced hands remains an effective and specific assay.

Health and safety in the catering industry

There is evidence that the catering industry has high levels of work-related injury and disease. This study examined the incidence, nature and causes of work-related injury and disease among 315 catering students, at a large school of catering in the west of Ireland, over a 10 month academic year. A high incidence of accidents that caused injury was found. Cuts and lacerations, arising from accidents with knives, were the most common injuries seen, followed by burns and scalds from handling hot liquids. A significant level of work-related dermatitis was also recorded. Trainee chefs were identified as an occupational group with a high risk of occupational injury and disease. This group would benefit from vaccination against tetanus. Work-related injuries and disease generated a significant workload for the student health unit, which in itself is a good reason for catering establishments to make use of occupational health services. Health and safety procedures need to be audited and constantly reviewed at a local level. Further research is necessary to more accurately determine the incidence, nature and leading causes of work-related injury and disease in the catering industry in Ireland. This would help in the planning and implementation of an effective health and safety management system.

The architecture of Mg(II) centres in MAPO-36 solid acid catalysts

The local structure around Mg2+ ions of a Magnesium substituted aluminophosphate, with the ATS structure (MgAPO-36, Mg/P=0.08), in the as-prepared and calcined state has been investigated by Mg K-edge XAS spectroscopy. High quality XAS data were collected using the solid-state fluorescence detector. Mg2+ is found to replace tetrahedrally co-ordinated Al3+ in the as-prepared state and remained intact even after calcination, thus yielding a highly active, solid acid catalyst.

Effect of Si(IV) substitution on the stability of microporous ZnAPSO-44 solid acid catalysts: a combined XAS/XRD study

The combined XAS/XRD technique has been used to investigate the stability of the microporous structure during calcination process for a series of ZnAPSO-44 materials. Incorporation of large amounts of Zn is found to produce materials that are unstable upon removal of the structure directing organic template molecule. However, simultaneous incorporation of Si is found to increase the thermal stability of the materials, yielding catalysts that are well suited for acid catalysed reactions.

Molecular phylogenetics of leafrollers application to DNA diagnostics

Accurate and rapid diagnosis of taxa whether they be welldefined species or biotypes is of crucial importance to quarantine pest management and research Recent developments in DNA technology has resulted in a range of molecular techniques being available for use in such applications We have employed a phylogenetically focussed approach in the development of a diagnostic key to distinguish a range of leafroller species (Lepidoptera Tortricidae) using DNA sequence data derived from a 23 kb region of the mitochondrial genome containing the genes cytochrome oxidase I and II Phylogenetic analysis has revealed clear relationships between taxa although the genus Apoctena does not appear monophyletic The most appropriate diagnostic characters are either those which are phylogenetically informative either synapomorphies or autapomorphies A standardised approach to data collection is advocated for future studies

Low-dose methotrexate is ineffective in primary biliary cirrhosis: long-term results of a placebo-controlled trial

BACKGROUND & AIMS

New treatments for primary biliary cirrhosis (PBC) need to be evaluated. We conducted a single-center double-blind, randomized trial of methotrexate, 7.5 mg/wk (n = 30), vs. placebo (n = 30) for up to 6 years in PBC.

METHODS

Methods included three monthly symptom assessment and liver function tests and liver biopsy and gastroscopy at baseline, after 2 years, and after 4-6 years.

RESULTS

Patients randomized to methotrexate had, compared with patients randomized to placebo, (1) significantly lower on-treatment serum alkaline phosphatase, gamma-glutamyltransferase, immunoglobulin (Ig) M, IgG, and (after 24 months) aspartate aminotransferase and alanine aminotransferase levels (P < 0.02-0.001 by analysis of covariance to adjust for baseline differences); (2) a nonsignificant trend toward lower on-treatment pruritus scores; (3) similar on-treatment Knodell inflammatory scores but nonsignificant trends toward lower Knodell fibrosis score and less ductopenia; (4) a trend toward greater increases in serum bilirubin level and Mayo score with time (both significant after 5 years of follow-up); and (5) a 2.9-fold (95% confidence interval, 0.85-10.25-fold) increase the rate of death or liver transplantation as a result of liver disease during or after the trial (P = 0.09) in a Cox multivariate regression analysis compared with patients randomized to placebo.

CONCLUSIONS

These results do not support the clinical use of low-dose methotrexate in PBC.

Primary biliary cirrhosis shows association with genetic polymorphism of tumour necrosis factor alpha promoter region

BACKGROUND/AIMS

Primary biliary cirrhosis is an autoimmune disease in which increased prevalence in first-degree relatives and an association with HLA DR8 suggest a genetic background. TNFalpha is a mediator of inflammation and immunity, and is implicated in the pathogenesis of primary biliary cirrhosis, ex vivo studies having shown reduced production of TNFalpha by lymphocytes from patients. Our group has previously described a biallelic promoter-region polymorphism of the TNFA gene at position -308, and demonstrated that the rare allele, TNF*2, has increased promoter function compared with the common allele, TNF*1. A further biallelic base change has been described in the TNFA gene at -238. We conducted a case-control study to assess association of these gene polymorphisms with primary biliary cirrhosis.

METHODS

Ninety-one patients and 213 controls were genotyped for both TNFA loci using restriction fragment length polymorphism analysis of PCR products.

RESULTS

The high production TNFA-308*2 allele was significantly under-represented among subjects with primary biliary cirrhosis (27.5% PBC, 41.6% controls, p=0.02, pc=0.04, OR for carriage of TNF*1/*1 genotype=1.89, CI=1.10-3.32). No association was shown with the TNFA -238 polymorphism.

CONCLUSION

Primary biliary cirrhosis is associated with reduced carriage of TNF*2. This is in keeping with a protective role of TNFalpha against the disease.

Effect of acute bile acid pool depletion on total and ionized calcium concentrations in human bile

Although calcium salts are important components of gallstones, there are few data on the total and ionized calcium content of human bile. Therefore, in 14 fasting T-tube patients studied 7-11 days after cholecystectomy, we measured bile flow, bile acid [BA], total [CaTOT] and free ionized [Ca++] calcium concentrations, in 20-30 min bile collections during acute BA pool depletion induced by 6-8 h of continuous bile drainage. During washout of the BA pool there were parallel falls in bile flow, BA output and total calcium output (correlation coefficients ranging from 0.59 to 0.99; P < 0.02-0.001). In 12 of the 14 patients, [CaTOT] also fell (from 1.84 +/- 0.29 to 1.32 +/- 0.34 mmol L-1) in parallel with [BA] (from 34.0 +/- 14.0 to 8.2 +/- 8.0 mmol L-1; r = 0.75-0.98; P < 0.005). In contrast, biliary [Ca++] remained virtually unchanged. These data suggest that the BAs are linked to the bound, rather than to the free, ionized, fraction of biliary calcium, which is consistent with in vivo calcium binding by BAs. A model is proposed in which BA-induced biliary calcium secretion results from (i) bile acid-induced water flow via solvent drag; and (ii) calcium binding in the bile canaliculus by bile acids, which induces paracellular diffusion of Ca++, thereby maintaining [Ca++] independent of [BA].

Changes in serum calcium levels influence biliary calcium levels in humans

BACKGROUND/AIMS

There are few data on the influence of serum calcium on biliary total and ionized calcium levels in humans. The aims of the study were to increase serum calcium levels short-term by intravenous calcium infusion and study the resultant changes in total and ionized calcium concentrations ([CaTOT] and [Ca2+]) in T-tube bile.

METHODS

Serum and biliary total and ionized calcium concentrations were measured over an 8-hour period in 7 postcholecystectomy patients with T tubes before, during, and after a 4-hour intravenous infusion of 10% calcium gluconate.

RESULTS

During the infusion, serum [CaTOT] increased from 2.08 +/- 0.14 mmol/L (mean +/- SD) to 3.18 +/- 0.33 mmol/L, and serum [Ca2+] increased from 1.13 +/- 0.13 mmol/L to 1.68 +/- 0.13 mmol/L. After a 20-40-minute time lag, there were corresponding increases in biliary [CaTOT] from 1.90 +/- 0.45 mmol/L to 2.80 +/- 0.52 mmol/L and in biliary [Ca2+] from 0.70 +/- 0.11 mmol/L to 1.19 +/- 0.16 mmol/L. When the data were pooled, serum [Ca2+] showed significant correlations with both biliary [CaTOT] (n = 128; r = 0.56; P < 0.001) and biliary [Ca2+] (n = 128; r = 0.64; P < 0.001).

CONCLUSIONS

These results support the hypothesis that the biliary tree is freely permeable to calcium ions and that serum calcium level is one determinant of biliary calcium concentration. Our data may also explain the observation that patients with hypercalcemia are reported to have a greater than normal prevalence of calcified gallstones.

Acid-base transport systems in a polarized human intestinal cell monolayer: Caco-2

Acid-base transport systems have been incompletely characterized in intact intestinal epithelial cells. We therefore studied the human cell line Caco-2, cultured on Teflon membranes to form confluent monolayers with apical microvilli on transmission electron microscopy and progressive enrichment in microvillar hydrolases. Monolayers (16- to 25-day-old), loaded with the pH-sensitive dye BCECF-AM (2',7'-bis (carboxyethyl)-5-carboxyfluorescein), were mounted in a spectrofluorometer cuvette to allow selective superfusion of apical and basolateral surfaces with Hepes- or HCO(3-)-buffered media. Intracellular pH (pHi) was measured by dual-excitation spectrofluorimetry; calibration was with standards containing nigericin and 110 mM K+ corresponding to measured intracellular [K+] in Caco-2 cell monolayers. In HCO(3-)-free (Hepes-buffered) media, bilateral superfusion with 1 mM amiloride or with Na(+)-free media reversibly inhibited pHi recovery from an intracellular acid load (NH4Cl pulse) by 86 and 98% respectively. Selective readdition of Na+ to the apical or basolateral superfusate also induced a pHi recovery, which was inhibited by ipsilateral but not by contralateral amiloride (1 mM). The pHi recovery induced by apical Na+ readdition had a Michaelis constant (Km) for Na+ of 30 mM and a relatively high inhibitor constant (Ki) for amiloride of 45.5 microM. Initial pHi in HCO(3-)-buffered media was lower than in the absence of HCO3- (7.35 vs. 7.80). pHi recovery from an acid load in HCO3- was Na- dependent but was inhibited only 18% by 1 mM amiloride. The amiloride-independent pHi recovery was inhibited 49% by pre-incubation of cells in 5 mM DIDS (4,4'-diisothiocyanatostilbene-2,2'-disulphonic acid). These data suggest that Caco-2 cells possess: (a) both apical and basolateral membrane Na(+)-H+ exchange mechanisms, the apical exchanger being relatively resistant to amiloride, similar to apical Na(+)-H+ exchangers in several normal epithelia; and (b) a Na(-)-dependent HCO3- transport system, either Na(+)-HCO3- cotransport or Na(-)-dependent Cl(-)-HCO3- exchange.

Hepatitis C virus in autoimmune liver disease in the UK: aetiological agent or artefact?

Hepatitis C virus antibody titres (anti-HCV) were measured in serum from 122 patients with autoimmune liver disease (96 with primary biliary cirrhosis and 26 with autoimmune chronic active hepatitis using three generations of enzyme immunoassay (EIA): first generation--Ortho, EIA1; second generation--Abbott, EIA2; and third generation--Murex, EIA3. Anti-HCV was below the positive cut-off level in all 26 autoimmune chronic active hepatitis patients for all tests, while seropositivity values in primary biliary cirrhosis were 31% (EIA1), 14% (EIA2), and 0% (EIA3). In primary biliary cirrhosis, anti-HCV values as measured by all three tests correlated positively with serum IgG concentrations, serum storage time, and a number of other indices of hepatic dysfunction. Multiple regression analysis showed that anti-HCV values were independently affected by both serum IgG and the length of storage time, although the magnitude of the effects varied between tests. When all three multiple regression models were applied to an extreme clinical example, however, EIA3 was least likely to give a false-positive result. The difference in test performance was emphasised further by examination of anti-HCV values in nine primary biliary cirrhosis patients (confirmed negative by recombinant immunoblot assay 2) in whom serial samples were tested (seven to 14 per patient, stored for one to 138 months). Apparent anti-HCV values (EIA1 and EIA2) increased with increasing serum storage time, but were unchanged when measured by EIA3. A similar pattern was evident in a limited study of five autoimmune chronic active hepatitis patients. As the second generation EIA is in widespread use and confirmatory testing is not always available, the effect of serum storage in addition to hyperglobulinaemia should be considered in the interpretation of positive results in auto immune and in other types of chronic liver disease.

Gall stone recurrence and its prevention: the British/Belgian Gall Stone Study Group's post-dissolution trial

The British/Belgian Gall Stone Study Group (BBGSG) post-dissolution trial was a prospective, multicentre, randomised, double blind trial of: (i) low dose ursodeoxycholic acid, (ii) placebo, and (iii) a high fibre, low refined carbohydrate diet in the prevention of gall stone recurrence in patients with complete gall stone dissolution. Further aims included establishing the timing and frequency of recurrence and its association with biliary symptoms, a comparison of the sensitivity of ultrasonography v oral cholecystectography in detecting recurrent stones, and a search for risk factors predicting recurrence. Ninety three patients entered the study, and 82 were followed up for up to five years (mean (SEM) 28 (1.5) months) with six monthly ultrasonography and yearly oral cholecystectography. There were 21 recurrences (26 by oral cholecystectography or ultrasonography, or both), only two of which were symptomatic, which were detected between 12 and 42 months after trial entry. This corresponded to an actuarial recurrence rate of 33.9 (7.0%) by lifetable analysis at 42 months and subsequently. There were four recurrences in the ursodeoxycholic acid, six in the placebo, and 11 in the diet groups, corresponding to 21.9 (9.9)%, 27.4 (10.1)%, and 45.8 (12.4)% respectively at 42 months by lifetable analysis (NS). Variables including age, obesity, menopausal state, pregnancy, and oestrogen containing drugs were not shown to affect recurrence rate. Men had more frequent recurrence than women (NS). Patients who had had multiple stones experienced more recurrences than did those with single stones (NS). Recurrence did not occur in patients who took non-steroidal anti-inflammatory drugs (NSAIDs) (p < 0.02). The stone free interval between stone dissolution and trial entry proved to be important--those stone free > nine months had a recurrence rate of only 12.7 (6.0)% at 42 months compared with 55.4 (12.5)% in those stone free < nine months (p < 0.01). There was imbalance between the ursodeoxycholic acid and placebo groups for this factor, and after applying a statistical correction, the adjusted recurrence rate in the ursodeoxycholic acid group was 15% compared with 30% in both placebo and diet groups (NS). These data suggest that after medical dissolution, the risk of gall stone recurrence is not reduced by a high fibre, low refined carbohydrate diet: it may be lowered, but not abolished, by low dose ursodeoxycholic acid.

Calcium and carbonate ion concentrations in gallbladder and hepatic bile

Calcium carbonate is a major component of gallstones, but there are few data on calcium and carbonate (CO3(2-)) concentrations in human bile. Therefore, in patients undergoing cholecystectomy for gallstones, total [CaTOT] and free ionized [Ca2+] calcium concentrations, pH, PCO2, and total [CO2] were measured and [CO3(2-)] was derived in gallbladder and hepatic bile (aspirated anaerobically at surgery or from T tubes). Gallbladder bile had lower pH (6.96 vs. 7.30) and total [CO2] (14.1 vs. 21.6 mmol/L), higher PCO2 (53.8 vs. 40.2 mm Hg), lower [CO3(2-)] (2.52 vs. 6.11 x 10(5) mol/L) and lower [Ca2+] x [CO3(2-)] ion product (1.88 vs. 4.74 x 10(-8) mol/L) than did hepatic bile. Gallbladder bile pH correlated positively with total [CO2], [CO3(2-)], and [Ca2+] x [CO3(2-)] but negatively with PCO2. Patients with surface gallstone calcification had similar gallbladder bile [CaTOT] and [Ca2+] but higher gallbladder bile pH (7.30 vs. 6.90), lower PCO2 (42.9 vs. 57.2 mm Hg), higher [CO3(2-)] (7.29 vs. 1.84 x 10(-5) mol/L), and higher [Ca2+] x [CO3(2-)] ion product [4.73 vs. 1.45 x 10(-8) (mol/L)2] than those with radiolucent gallstones. There were no differences in these parameters between patients with cholesterol stones and those with pigment stones. These data suggest that the human gallbladder acidifies bile by secreting hydrogen ion and that impairment of this secretion is one cause of calcified gallstone formation in humans.

Combination therapy with oral ursodeoxycholic and chenodeoxycholic acids: pretreatment computed tomography of the gall bladder improves gall stone dissolution efficacy

In a five year study, 55 patients with radiolucent gall stones were treated with the combination of 7.5 mg chenodeoxycholic acid (CDCA) and 5.0 mg ursodeoxycholic acid (UDCA)/kg/day--that is, half the monotherapeutic doses. Side effects were few but four patients could not tolerate the prescribed bile acids because of diarrhoea or nausea. Analysis of fasting duodenal bile confirmed that CDCA+UDCA converted supersaturated into unsaturated bile but the saturation indices did not predict the dissolution response. By actuarial analysis, the confirmed (by ultrasound x2) complete gall stone dissolution rates in all 55 patients were mean (SEM) 29 (7)% at 12 and 44 (8)% at 24 months. The advent of routine computed tomography before treatment enabled comparison of dissolution efficacy in those screened by computed tomography (n = 24), whose maximum gall stone attenuation was less than 100 Hounsfield units, with that in those not screened (n = 29). Although stone size and number were comparable, patients screened by computed tomography had significantly better dissolution rates (p less than 0.025) than those not screened in this way. At 12 months, partial or complete gall stone dissolution rates were 93 (7)% in the screened and 55 (11)% in the non-screened patients. At 18 months, complete dissolution rates were 64 (12%) and 20 (9)% respectively. Computed tomography before treatment is cost effective in selecting those patients likely to achieve gall stone dissolution on treatment with UDCA+CDCA.

Androgen associated hepatocellular carcinoma with an aggressive course

The hepatocellular carcinomas that develop in patients treated with androgens have previously been associated with a benign clinical outcome. We describe a man who developed a hepatocellular carcinoma after 24 years of androgen treatment, whose tumour initially showed partial regression after withdrawal of androgens but subsequently pursued an aggressive and fatal course.

Final outcome of ursodeoxycholic acid treatment in 126 patients with radiolucent gallstones

One hundred and twenty-six patients with radiolucent gallstones in 'functioning' gallbladders were treated with 8-10 mg ursodeoxycholic acid (UDCA) kg/day and followed to a treatment conclusion. Complete or partial gallstone dissolution was achieved in 74 (59 per cent). However, only 22 achieved complete gallstone dissolution, as judged by two normal oral cholecystograms; ultrasonograms were performed in 16 of these patients, and all were normal. UDCA was stopped in 76 patients: because of cystic duct obstruction (n = 12), severe biliary pain (n = 13), non-response (n = 25) or partial stone dissolution with arrested progress (n = 26). Life-table analysis showed that complete gallstone dissolution rates at four years were 25-30 per cent (two normal oral cholecystograms) and 17-19 per cent (two normal oral cholecystograms plus one ultrasonogram). All patients with complete gallstone dissolution had shown partial stone dissolution at 6-12 months; of those with partial stone dissolution at six months, only 25 per cent went on to complete gallstone dissolution, and then always within two years. Efficacy correlated inversely with stone size but not with age, sex, obesity or on-treatment saturation indices. Acquired surface gallstone calcification developed in 13 patients (life-table analysis 22 +/- 7 per cent at four years); none of these patients achieved complete gallstone dissolution and only five achieved partial stone dissolution. Thus, despite relatively high partial gallstone dissolution rates, the ultimate efficacy of UDCA in achieving complete gallstone dissolution is low.