321 UNMET NEEDS AFTER STROKE

Background

Unmet needs, such as lack of access to rehabilitation, support and information, are experienced by a high proportion of stroke survivors after discharge from acute and rehabilitation services. The UK guidelines on stroke (2016) recommend that all patients should be offered a structured health and social care review at 6 months post-stroke. However, no such clinics exist to date in Ireland. We aimed to explore the extent of unmet needs in the catchment area of a large teaching hospital.

Methods

A random selection of patients 6-months post-stroke were contacted by telephone and unmet needs were assessed using a validated tool, Post-Stroke Checklist. Following analysis of data, the need for a pilot clinic was identified. A separate random selection of patients discharged from acute services 6 months previously were invited to attend a review clinic. Patients were assessed using an adapted version of the Greater Manchester Stroke Assessment Tool. Assessments were conducted jointly by a physiotherapist and a speech and language therapist, and appropriate onward referrals were made.

Results

Telephone clinic: 51 patients completed the checklist. The most prevalent symptoms reported were fatigue (75%), reduced participation in hobbies and activities, decline in cognition (61%) and mobility problems (59%). Review clinic: 21 patients attended. The most prevalent symptoms reported were reduced memory/concentration (71%), low mood (71%), unintentional weight loss/gain (62%), and reduced mobility (43%). Onward referrals were made for in 16/21 (76%) cases; physiotherapy (n=12), occupational therapy (n=7), speech and language therapy (n=7), clinical nutrition (n=5), social work (n=7), psychology (n=5).

Conclusion

Data from this exploratory study supports previous research indicating a high number of stroke survivors with unmet needs. This highlights the importance of establishing post-acute stroke review clinics and pathways in the Irish setting.

48 EXPLORING RESIDENTS’ PERCEPTIONS OF SOCIAL AND LEISURE OCCUPATIONAL CHOICE WITHIN NATIONAL NURSING HOME CARE FACILITIES

Background

National standards state that nursing homes in Ireland must provide residents with a variety of engaging activities that accommodate their needs and preferences. Despite this, residents are at risk of experiencing occupational deprivation as a result of limited choices within these settings. Due to the subjective nature of occupational choice, the objective of this study is to analyse residents’ perceptions of leisure and social occupational choice in nursing homes in Ireland.

Methods

The study adopted a qualitative-descriptive design. Six residents from three different nursing homes participated in two semi-structured interviews that analysed their leisure and social occupational engagement within their nursing home.

Results

The data identified two main themes that were divided into six related sub-themes. Residents' felt their social and leisure occupational choice was influenced by: (1) environmental factors (the cultural, social, physical, and temporal contexts of the nursing home) and (2) personal attributes (residents' health status and personal attitudes).

Conclusion

Residents' leisure and social occupational choices are substantially influenced by the cultural context of the nursing home. This stresses the significant need for person-centred care in nursing homes, in order to promote occupational choice. The findings also highlight the benefits of accessible communal spaces to enable unstructured social interaction. Occupational therapists are essential to support the leisure and social occupational choices of nursing home residents and minimise occupational deprivation, by building residents’ skills, providing staff education and modifying tasks and/or the environment.

Defining the role of neutrophils in the lung during infection: Implications for tuberculosis disease

Neutrophils are implicated in the pathogenesis of many diseases involving inflammation. Neutrophils are also critical to host defence and have a key role in the innate immune response to infection. Despite their efficiencies against a wide range of pathogens however, their ability to contain and combat Mycobacterium tuberculosis (Mtb) in the lung remains uncertain and contentious. The host response to Mtb infection is very complex, involving the secretion of various cytokines and chemokines from a wide variety of immune cells, including neutrophils, macrophages, monocytes, T cells, B cells, NK cells and dendritic cells. Considering the contributing role neutrophils play in the advancement of many diseases, understanding how an inflammatory microenvironment affects neutrophils, and how neutrophils interact with other immune cells, particularly in the context of the infected lung, may aid the design of immunomodulatory therapies. In the current review, we provide a brief overview of the mechanisms that underpin pathogen clearance by neutrophils and discuss their role in the context of Mtb and non-Mtb infection. Next, we examine the current evidence demonstrating how neutrophils interact with a range of human and non-human immune cells and how these interactions can differentially prime, activate and alter a repertoire of neutrophil effector functions. Furthermore, we discuss the metabolic pathways employed by neutrophils in modulating their response to activation, pathogen stimulation and infection. To conclude, we highlight knowledge gaps in the field and discuss plausible novel drug treatments that target host neutrophil metabolism and function which could hold therapeutic potential for people suffering from respiratory infections.

Distal urethral carcinoma: Contemporary management with phallus preserving techniques

INTRODUCTION

Primary urethral carcinoma is a rare clinical entity with an incidence of 1 case per million in the United Kingdom. Cancers of the distal urethra are most commonly of squamous subtype and often associated with Human Papilloma Virus infection. Penile preserving techniques are recommended in tumours of the pendulous urethra with a number of surgical approaches described. Herein, we describe the surgical management of 7 patients presenting with primary urethral carcinoma.

METHODS

Seven patients diagnosed with primary urethral carcinoma of the distal urethra were identified using a prospectively maintained penile cancer database at our institution from May 2017 to November 2020.

RESULTS

The mean age at presentation was 56.5 (33-80) years. Presenting symptoms included visible lesion, LUTS and a groin mass. Three patients had lesions located within the glanular urethra and had a distal urethrectomy and primary closure. Two patients with lesions extending proximal to the glanular urethra and into or beyond the fossa navicularis had a distal urethrectomy with a hypospadic neomeatus formation. One patient with tumour extending into the glans penis underwent distal urethrectomy and partial glansectomy with split thickness skin graft. A partial penectomy was performed for one patient with urethral tumour invading the corporal heads. Mean follow-up was 23.4 (±17.0) months. There have been no disease recurrences to date.

CONCLUSION

Penile preserving techniques are feasible in patients with tumours of the pendulous urethra and do not appear to compromise local control.

The largest prison outbreak of TB in Western Europe investigated using whole-genome sequencing

BACKGROUND: In March 2011, the Department of Public Health East in Ireland were notified of two cases of TB in two prisoners sharing a cell. We define the resulting outbreak and highlight the role of public health and laboratory-based molecular epidemiology in mapping and control of a prison outbreak.METHODS: Cases were identified through clinical presentation, contact tracing, case-finding exercise or enhanced laboratory surveillance. Mycobacterium tuberculosis isolates were genotyped and underwent whole-genome sequencing (WGS).RESULTS: Of the 34 cases of TB linked to the outbreak, 27 were prisoners (79%), 4 prison officers (12%) and 3 community cases (9%). M. tuberculosis was isolated from 31 cases (culture positivity: 91%). A maximum of six single-nucleotide polymorphisms separated the isolates, with 22 being identical, suggestive of a highly infectious 'super-spreader´ within the prison. Isolates belonged to the Beijing sub-lineage, and were susceptible to first-line anti-TB agents. A case-finding exercise incidentally detected a prisoner with multidrug-resistant TB. Of the 143 prison officers screened, 52% had latent TB infection. Litigation costs exceeded five million euros.CONCLUSION: This constitutes the largest prison outbreak of TB in Western Europe investigated using WGS. A robust prison entry TB screening and education programme is required to effect better TB control, and prevent future outbreaks and attendant litigation.

Containment of procedure-associated aerosols by an extractor tent: effect on nebulized drug particle dispersal

Background

Several medical procedures involving the respiratory tract are considered as ‘aerosol-generating procedures’. Aerosols from these procedures may be inhaled by bystanders, and there are consequent concerns regarding the transmission of infection or, specific to nebulized therapy, secondary drug exposure.

Aim

To assess the efficacy of a proprietary high-efficiency-particulate-air-filtering extractor tent on reducing the aerosol dispersal of nebulized bronchodilator drugs.

Methods

The study was conducted in an unoccupied outpatient room at St. James's Hospital, Dublin, Ireland. A novel real-time, fluorescent particle counter, the Wideband Integrated Bioaerosol Sensor (WIBS), monitored room air continuously for 3 h. Baseline airborne particle count and count during nebulization of bronchodilator drug solutions were recorded.

Findings

Nebulization within the tent prevented any increase over background level. Nebulization directly into room air resulted in mean fluorescent particle counts of 4.75 x 10⁵/m³ and 4.21 x 10⁵/m³ for Ventolin and Ipramol, respectively, representing more than 400-fold increases over mean background level. More than 99.3% of drug particles were <2 μm in diameter and therefore small enough to enter the lower respiratory tract.

Conclusion

The extractor tent was completely effective for the prevention of airborne spread of drug particles of respirable size from nebulized therapy. This suggests that extractor tents of this type would be efficacious for the prevention of airborne infection from aerosol-generating procedures during the COVID-19 pandemic.

Can you detect early dementia from an email? A proof of principle study of daily computer use to detect cognitive and functional decline

OBJECTIVE

To determine whether multiple computer use behaviours can distinguish between cognitively healthy older adults and those in the early stages of cognitive decline, and to investigate whether these behaviours are associated with cognitive and functional ability.

METHODS

Older adults with cognitive impairment (n = 20) and healthy controls (n = 24) completed assessments of cognitive and functional abilities and a series of semi-directed computer tasks. Computer use behaviours were captured passively using bespoke software.

RESULTS

The profile of computer use behaviours was significantly different in cognitively impaired compared with cognitively healthy control participants including more frequent pauses, slower typing, and a higher proportion of mouse clicks. These behaviours were significantly associated with performance on cognitive and functional assessments, in particular, those related to memory.

CONCLUSION

Unobtrusively capturing computer use behaviours offers the potential for early detection of neurodegeneration in non-clinical settings, which could enable timely interventions to ultimately improve long-term outcomes.

Molecular epidemiology of multi- and extensively-drug-resistant Mycobacterium tuberculosis in Ireland, 2001-2014

OBJECTIVES

The primary objective of this work was to examine the acquisition and spread of multi-drug resistant (MDR) tuberculosis (TB) in Ireland.

METHODS

All available Mycobacterium tuberculosis complex (MTBC) isolates (n = 42), from MDR-TB cases diagnosed in Ireland between 2001 and 2014, were analysed using phenotypic drug-susceptibility testing, Mycobacterial-Interspersed-Repetitive-Units Variable-Number Tandem-Repeat (MIRU-VNTR) genotyping, and whole-genome sequencing (WGS).

RESULTS

The lineage distribution of the MDR-TB isolates comprised 54.7% Euro-American, 33.3% East Asian, 7.2% East African Indian, and 4.8% Indo-Oceanic. A significant association was identified between the East Asian Beijing sub-lineage and the relative risk of an isolate being MDR. Over 75% of MDR-TB cases were confirmed in non-Irish born individuals and 7 MIRU-VNTR genotypes were identical to clusters in other European countries indicating cross-border spread of MDR-TB to Ireland. WGS data provided the first evidence in Ireland of in vivo microevolution of MTBC isolates from drug-susceptible to MDR, and from MDR to extensively-drug resistant (XDR). In addition, they found that the katG S315T isoniazid and rpoB S450L rifampicin resistance mutations were dominant across the different MTBC lineages.

CONCLUSIONS

Our molecular epidemiological analyses identified the spread of MDR-TB to Ireland from other jurisdictions and its potential to evolve to XDR-TB.

Comparison of capillary and venous blood in the analysis of concentration and function of leucocyte sub-populations

PURPOSE

Compare capillary and venous blood in the analysis of concentration and function of leucocyte sub-populations. This study hypothesised that capillary samples may be used in a site-specific manner as an alternative source of blood samples for assays of leucocyte concentration and neutrophilic phagocytic function and reactive oxygen species (ROS) production, allowing acquisition of multiple samples to better monitor transient but significant post-exercise immune modulation.

METHODS

Resting blood samples were simultaneously obtained from vein, finger and earlobe of healthy subjects (n = 10, age: 25.1 ± 3.1 years). Leucocyte concentrations were measured using a five-part differential haematological analyser. Leucocyte sub-populations (CD3, CD4, CD8, CD19, CD56, CD14) and granulocytic functional-related (CD11b, CD18, CD16b, CD66b) surface antigen markers, neutrophil phagocytosis (FITC-labelled Escherichia coli) and stimulated ROS production (DHR) were quantified utilizing flow cytometry. A MANOVA (α < 0.05 significance) analysed the effects of the different sampling sites in the concentrations of leucocyte populations, their surface antigen expression and granulocytic functions.

RESULTS

Leucocyte concentration and neutrophilic ROS production yielded non-significant differences between sampling sites. Expression of granulocytic surface antigens was increased in both capillary sites compared to venous site (p = 0.008), particularly for adhesion markers CD11b/CD18. The percentage of neutrophils performing phagocytosis was higher in venous samples compared to finger (p = 0.025). Increased number of E. coli ingested was observed in venous sample compared to finger (p = 0.001) and to earlobe (p = 0.006).

CONCLUSION

Whilst attention must be paid for varying neutrophilic surface antigen expression and further studies are needed to establish appropriate reference ranges, this study supports the use of capillary blood samples in a site-specific manner to enhance sampling capabilities field-based research.

Mycobacterium avium complex pulmonary disease: characteristics and treatment in an Irish patient cohort

The prevalence of Mycobacterium avium complex (MAC) pulmonary disease is increasing globally. However, reliable national and international data relating to its epidemiology and management is lacking. During the period 2003-2014, MAC was isolated from the pulmonary samples of 75 patients at the Irish Mycobacteria Reference Laboratory (IMRL). Most patients (42, 56%) had underlying pulmonary disease, and 37 (49%) had clinical/radiographic characteristics consistent with MAC pulmonary disease. However, only 18 patients (24%) fulfilled internationally accepted criteria for diagnosis/treatment of this disease. Treatment was started in 13 (72%) of these cases, which is similar to internationally published treatment rates. The diagnosis of significant MAC pulmonary disease can be difficult, and treatment is not always warranted even when diagnostic criteria are met.

An unusual lung mass post stem cell transplantation

We report a case of Mycobacterium kansasii presenting as an obstructing endobronchial mass in a patient post stem cell transplant. The patient had a complete clinical, microbiological, and radiological response to anti-tuberculous treatment. To our knowledge, this is the first case of M. kansasii presenting post transplant with an obstructing lung mass simulating relapse or post-transplant lymphoma.

Niche differentiation of ammonia-oxidising archaea (AOA) and bacteria (AOB) in response to paper and pulp mill effluent

Sediment organic loading has been shown to affect estuarine nitrification and denitrification, resulting in changes to sediment biogeochemistry and nutrient fluxes detrimental to estuarine health. This study examined the effects of organic loading on nutrient fluxes and microbial communities in sediments receiving effluent from a paper and pulp mill (PPM) by applying microcosm studies and molecular microbial ecology techniques. Three sites near the PPM outfall were compared to three control sites, one upstream and two downstream of the outfall. The control sites showed coupled nitrification-denitrification with minimal ammonia release from the sediment. In contrast, the impacted sites were characterised by nitrate uptake and substantial ammonia efflux from the sediments, consistent with a decoupling of nitrification and denitrification. Analysis of gene diversity demonstrated that the composition of nitrifier communities was not significantly different at the impacted sites compared to the control sites; however, analysis of gene abundance indicated that whilst there was no difference in total bacteria, total archaea or ammonia-oxidising archaea (AOA) abundance between the control and impacted sites, there was a significant reduction in ammonia-oxidising bacteria (AOB) at the impacted sites. The results of this study demonstrate an effect of organic loading on estuarine sediment biogeochemistry and highlight an apparent niche differentiation between AOA and AOB.

Barriers to accepting and completing latent tuberculosis infection treatment

Treatment of Latent Tuberculosis Infection (LTBI) is an important component of any TB control strategy. Acceptance and completion of treatment is poor. We undertook this study to identify barriers to acceptance & completion of treatment. Patients attending TB clinics completed a self-administered survey. Medical notes and electronic pharmacy records were reviewed. 143 surveys were completed. 70 (49%) completed treatment. Patients were less likely to accept treatment (p = 0.01, RR 0.781, CI 0.643-0.950) and less likely to complete treatment (p = 0.01, RR 0.640, CI 0.462-0.885) when concerned about the side effects of LTBI medication. Completion of LTBI treatment is sub-optimal. The major barrier identified was fear about side effects caused by LTBI medications.

Therapeutic aerosol bioengineering of targeted, inhalable microparticle formulations to treat Mycobacterium tuberculosis (MTb)

Therapeutic aerosol bioengineering (TAB) of Mycobacterium tuberculosis (MTb) therapies using inhalable microparticles offers a unique opportunity to target drugs to the site of infection in the alveolar macrophages, thereby increasing dosing in the lungs and limiting systemic exposure to often toxic drugs. Previous work by us used sophisticated, high content analysis to design the optimal poly(lactide-co-glycolic) acid (PLGA) microparticle for delivery of drugs to alveolar macrophages. Herein, we applied this technology to three different anti-MTb drugs. These formulations were then tested for encapsulation efficiency, drug-release, in vitro killing against MTb and aerosol performance. Methods for encapsulating each of the drugs in the PLGA microparticles were successfully developed and found to be capable of controlling the release of the drug for up to 4 days. The efficacy of each of the encapsulated anti-MTb drugs was maintained and in some cases enhanced post-encapsulation. A method of processing these drug-loaded microparticles for inhalation using standard dry powder inhaler devices was successfully developed that enabled a very high respirable dose of the drug to be delivered from a simple dry powder inhaler device. Overall, TAB offers unique opportunities to more effectively treat MTb with many potential clinical and economic benefits resulting.

Anal fistula: an unusual presentation of tuberculosis in a migrant health care professional

We present a case of a young health care professional from the Indian subcontinent, who presented with a low anal fistula and underwent exploration, debridement and fistulotomy twice. The initial working diagnosis was Crohn's disease. However, Mycobacterium tuberculosis, fully sensitive to all first-line drugs was cultured from the specimens sent from the second surgical procedure. On initiation of anti-tubercular therapy the symptoms improved within 5 weeks. The origin of the patient, high index of suspicion for non-infectious reactivation of tuberculosis in migrant health care workers, importance of a proper history taking including previous exposure and diagnostic workup is stressed.

Multi-drug resistant tuberculosis: experiences of two tertiary referral centres

Multi-drug resistant tuberculosis (MDR-TB) is associated with increased morbidity and mortality compared to drug-sensitive disease. Although MDR-TB is infrequent in Ireland, cases continue to be diagnosed in both Irish and foreign-born people. We conducted a clinical audit of 13 MDR-TB patients treated in two tertiary referral centers, the Mercy Hospital, Cork and St James's Hospital, Dublin between 2004 and 2009. The median age was 37 years. Eight patients (61.5%) were foreign-born, five (38.5%) were Irish-born. Seven patients (54%) have now stopped treatment; 6 (86%) were treated successfully and one (14%) defaulted. Mycobacterium tuberculosis isolates were resistant to a median of seven drugs. Eight patients (61.5%) developed ototoxicity from long-term aminoglycoside use. Our patients' treatment outcomes compare favourably with international reports despite a high degree of drug resistance. However, the high incidence of otoxicity is concerning.

Tuberculous dactylitis in the setting of low serum vitamin D: a case report

We present the case of a previously well patient who presented to the Emergency Department of a Dublin hospital with a tuberculous infection of his dominant index finger and a very low serum vitamin D level--this has been implicated in both primary and reactivation infections with Mycobacterium Tuberculosis. This case highlights and reviews both the importance of considering non-endemic pathologies in the setting of a patient base of diverse ethnicity, and the emerging importance of vitamin D in the immune response to M. tuberculosis infection. We discuss the relevant literature to highlight the background of this disease process, and the importance of a multidisciplinary approach to these patients.

Autophagy in the immune response to tuberculosis: clinical perspectives

A growing body of evidence points to autophagy as an essential component in the immune response to tuberculosis. Autophagy is a direct mechanism of killing intracellular Mycobacterium tuberculosis and also acts as a modulator of proinflammatory cytokine secretion. In addition, autophagy plays a key role in antigen processing and presentation. Autophagy is modulated by cytokines; it is stimulated by T helper type 1 (Th1) cytokines such as tumour necrosis factor (TNF)-α and interferon (IFN)-γ, and is inhibited by the Th2 cytokines interleukin (IL)-4 and IL-13 and the anti-inflammatory cytokine IL-10. Vitamin D, via cathelicidin, can also induce autophagy, as can Toll-like receptor (TLR)-mediated signals. Autophagy-promoting agents, administered either locally to the lungs or systemically, could have a clinical application as adjunctive treatment of drug-resistant and drug-sensitive tuberculosis. Moreover, vaccines which effectively induce autophagy could be more successful in preventing acquisition or reactivation of latent tuberculosis.

The Performance of Cu(In, Ga)Se2-Based Solar Cells in Conventional and Concentrator Applications

Cu(In, Ga)Se2 (CIGS) solar cells are under investigation for 1-sun and concentrator applications. Design criteria are examined and reveal that only grid design modifications are required. In the special case where cell width dimensions are 4–5 cm, an interdigitated design removes the back contact as a loss mechanism. Processing issues relating to the intrinsic ZnO layer are critical to optimal and reproducible cell performance. 1-sun and 20 sun performance of 17.7% are reported for different cells. The latter represents a 2.9% absolute improvement over the 1-sun control measurement. 20% performance is therefore a realistic goal. CIGS-based cells represent a viable concentrator technology.

Decision support systems for clinical radiological practice -- towards the next generation

The huge amount of information that needs to be assimilated in order to keep pace with the continued advances in modern medical practice can form an insurmountable obstacle to the individual clinician. Within radiology, the recent development of quantitative imaging techniques, such as perfusion imaging, and the development of imaging-based biomarkers in modern therapeutic assessment has highlighted the need for computer systems to provide the radiological community with support for academic as well as clinical/translational applications. This article provides an overview of the underlying design and functionality of radiological decision support systems with examples tracing the development and evolution of such systems over the past 40 years. More importantly, we discuss the specific design, performance and usage characteristics that previous systems have highlighted as being necessary for clinical uptake and routine use. Additionally, we have identified particular failings in our current methodologies for data dissemination within the medical domain that must be overcome if the next generation of decision support systems is to be implemented successfully.

Smoking prolongs the infectivity of patients with tuberculosis

We sought to establish if smokers on anti-tuberculosis treatment are more likely to have a prolonged period of infectivity, compared to non-smoking tuberculosis patients, in a low tuberculosis prevalence country. We conducted a cross-sectional, retrospective study in Ireland that recruited 53 microbiologically confirmed cases of pulmonary tuberculosis (PTB). The age-sex adjusted odds ratios (AOR) suggest that the infectivity status of PTB on treatment was four times more likely to be prolonged beyond 6-8 weeks, if the cases had a smoking history (AOR: 4.42; 95% CI: 1.23; 15.9). Smoking was associated with delayed sputum smear conversion in PTB patients on treatment.

How tumour necrosis factor blockers interfere with tuberculosis immunity

Tumour necrosis factor (TNF) is a potent inflammatory cytokine that plays an important role in immunity to numerous bacterial infections, including Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis (TB) in humans. Infliximab, adalimumab, certolizumab pegol and etanercept are anti-TNF agents used to treat a range of inflammatory/autoimmune diseases, such as rheumatoid arthritis. The use of some of these drugs has been linked to reactivation TB. In addition to blocking TNF-mediated immune responses, some anti-TNF drugs have been found to interfere with innate immune responses, such as phagolysosomal maturation and monocyte apoptosis, as well as cell-mediated responses, including interferon-gamma secretion by memory T cells, complement-mediated lysis of Mtb-reactive CD8+ T cells and increased regulatory T cell activity. This review summarizes some of the reported effects of TNF blockers on immune cell responses in the context of the observed clinical data on TB reactivation in patients on anti-TNF therapy.

The relation between anger and different forms of disgust: implications for emotion recognition impairments in Huntington's disease

Initial reports of emotion recognition in Huntington's disease (HD) found disproportionate impairments in recognising disgust. Not all subsequent studies have found this pattern, and a review of the literature to date shows that marked impairments in recognising anger are also often seen in HD. However, the majority of studies have based their conclusions on a single test of facial expression recognition. In the current study we revisit this issue of emotion recognition in HD to address whether the pattern found on one test of facial expression recognition generalised to another, and to different modalities using tests of emotion recognition from facial expressions, vocal expressions, and short verbal vignettes. The results showed evidence of impairments in recognising anger, fear and disgust across the three domains, with recognition of anger the most severely impaired. Given work identifying different subtypes of disgust that are associated with different facial features, a second study examined the recognition of three disgust expressions that healthy participants reliably associate with unpleasant tastes, unpleasant smells, and a more general elaborated or expanded form of disgust that includes reactions to violations of moral standards. The results showed a disproportionate impairment in recognising faces associated with the expanded form, the subtype most closely aligned with anger. We conclude that the related emotions of disgust and anger associated with social disapproval are frequently impaired in HD and discuss factors that might cause one emotion to show more severe impairments than the other.

Comparison of interferon {gamma} release assays and conventional screening tests before tumour necrosis factor {alpha} blockade in patients with inflammatory arthritis

OBJECTIVE

To compare the performance of two interferon gamma release assays (IGRAs) and conventional screening tests in patients with inflammatory arthritis undergoing screening for latent tuberculosis infection (LTBI) before treatment with anti-tumour necrosis factor alpha (anti-TNFalpha) compounds.

METHODS

Successive patients were subjected to conventional LTBI screening, including a tuberculin skin test (TST). The T-SPOT.TB test was performed on all patients and the QuantiFERON-TB Gold test was performed on a large subset. The results of the IGRAs were compared with the results of conventional screening tests.

RESULTS

A total 150 patients were evaluated. The majority (57.9%) had rheumatoid arthritis. Previous vaccination with Bacille Calmette-Guerin was confirmed in 82% of patients. No patient had received prior anti-TB treatment. A total of 57 patients (38.0%) had at least one positive conventional risk factor. In contrast, an unequivocally positive T-SPOT.TB test was seen in only 14/143 (9.8%). There was 98.2% agreement between the two IGRAs. Statistically significant associations were found between each of the IGRAs and both TST and risk history, but not chest x-ray (CXR). A positive IGRA result was significantly associated with increased age. TB was not reactivated in any patient during the follow-up period.

INTERPRETATION

This study suggests that IGRAs may be useful when screening for LTBI before anti-TNFalpha therapy in patients with immune-mediated inflammatory diseases. The observations reported here also highlight the inadequate performance of CXR as a marker of LTBI.

Leaving a bad taste in your mouth but not in my insula

Previous research has implicated regions of anterior insula/frontal operculum in processing conspecific facial expressions of disgust. It has been suggested however that there are a variety of disgust facial expression components which relate to the disgust-eliciting stimulus. The nose wrinkle is predominantly associated with irritating or offensive smells, the mouth gape and tongue extrusion with distaste and oral irritation, while a broader range of disgust elicitors including aversive interpersonal contacts and certain moral offenses are associated primarily with the upper lip curl. Using functional magnetic resonance imaging, we show that activity in the anterior insula/frontal operculum is seen only in response to canonical disgust faces, exhibiting the nose wrinkle and upper lip curl, and not in response to distaste facial expressions, exhibiting a mouth gape and tongue protrusion. Canonical disgust expressions also result in activity in brain regions linked to social cognition more broadly, including dorsal medial prefrontal cortex, posterior cingulate cortex, temporo-parietal junction and superior temporal sulcus. We interpret these differences in relation to the relative functional and communicative roles of the different disgust expressions and suggest a significant role for appraisal processes in the insula activation to facial expressions of disgust.

Anxiety predicts a differential neural response to attended and unattended facial signals of anger and fear

Behavioural evidence indicates that individual differences in anxiety influence the response to facial signals of threat. Angry and fearful faces represent qualitatively different forms of threat. Fearful faces are thought to signal the presence of a significant, yet undetermined source of danger within the environment, referred to as 'ambiguous threat'. In contrast, angry faces represent a more direct form of threat, often used in face-to-face encounters to exert dominance. Given the inherent differences between anger and fear, we hypothesised that anxiety would modulate the amygdala response to angry faces to a greater extent when attended. Following previous research, we expected anxiety to show a stronger relationship with the amygdala response to unattended fearful faces. In an event-related fMRI study, we presented images of two houses and two faces (consisting of fearful, angry or neutral expressions) in horizontal and vertical pairs around a central fixation cross, with participants instructed to attend to either the face or house stimuli. The results showed that higher anxiety levels produced an increased right amygdala response to viewer directed angry facial expressions (versus neutral or fearful faces) only when attended. By contrast, increased anxiety was associated with a greater left amygdala response to fearful faces (versus neutral or angry faces) in the unattended condition, with only borderline evidence for attended fear (relative to neutral). Our findings demonstrate the striking effects of personality in a non-clinical population, and show how this can distinguish the neural coding of anger and fear faces.

Connectivity from the ventral anterior cingulate to the amygdala is modulated by appetitive motivation in response to facial signals of aggression

For some people facial expressions of aggression are intimidating, for others they are perceived as provocative, evoking an aggressive response. Identifying the key neurobiological factors that underlie this variation is fundamental to our understanding of aggressive behaviour. The amygdala and the ventral anterior cingulate cortex (ACC) have been implicated in aggression. Using functional magnetic resonance imaging (fMRI), we studied how the interaction between these regions is influenced by the drive to obtain reward (reward–drive or appetitive motivation), a personality trait consistently associated with aggression. Two distinct techniques showed that the connectivity between the ventral ACC and the amygdala was strongly correlated with personality, with high reward–drive participants displaying reduced negative connectivity. Furthermore, the direction of this effect was restricted from ventral ACC to the amygdala but not vice versa. The personality-mediated variation in the pathway from the ventral anterior cingulate cortex to the amygdala provides an account of why signals of aggression are interpreted as provocative by some individuals more than others.

Extensively drug-resistant tuberculosis: first report of a case in Ireland

Extensively drug-resistant tuberculosis (XDR-TB) is an emerging global threat. Between 2002 and 2007 sixteen countries in the European Union (EU) reported at least one case of XDR-TB [1]. Infection is characterised by alarming mortality rates in both HIV and non-HIV populations.

Disgust sensitivity predicts the insula and pallidal response to pictures of disgusting foods

The anterior insula has been implicated in coding disgust from facial, pictorial and olfactory cues, and in the experience of this emotion. Personality research has shown considerable variation in individuals' trait propensity to experience disgust ('disgust sensitivity'). Our study explored the neural expression of this trait, and demonstrates that individual variation in disgust sensitivity is significantly correlated with participants' ventroanterior insular response to viewing pictures of disgusting, but not appetizing or bland, foods. Similar correlations were also seen in the pallidum and orofacial regions of motor and somatosensory cortices. Our results also accord with comparative research showing an anterior to posterior gradient in the rat pallidum reflecting increased 'liking' of foods [Smith, K. S. and Berridge, K. C. (2005) J. Neurosci., 25, 849-8637].

Proving the concept of a data broker as an emergent alternative to supra-enterprise EPR systems

Electronic Patient Records systems configured into large enterprise models have become the assumed best route forward. In England, as in several other countries, this has expanded to a major meta-enterprise procurement programme. However, concerns are raised that such systems lack user ownership, and experience from other sectors shows difficulties with large enterprise systems. At a time of great change and once again shifting organizations, is this move simply building large and ponderous edifices with unstable materials? Latest software engineering research is now demonstrating the potential of an alternative model, enabling trusted information brokers to search out in real time at point of use data held in registered local and departmental systems. If successful, this could enable a new and less cumbersome paradigm. The data could move where needed whatever the service configuration. A concept demonstrator has been built set in the context of health and social care in England. It is important for all technological support to the health sector to be reviewed as new technologies emerge so as to identify and exploit new opportunities, and the results of this 3 year project show that the health record information broker route merits further investigative research.