How medical students' trauma histories affect their clinical clerkship experiences

BACKGROUND

As the gender demographics of medical students have evolved over the past decades, it is important to understand potential stressors and challenges that may affect clinical learning experiences. This study investigated the prevalence of prior sexual assault (SA) and interpersonal violence (IPV) in medical students and how these affect their clinical clerkship experiences.

METHODS

A survey was distributed to third- and fourth-year medical students at a single institution in August 2022 querying respondents on demographics and prior experiences with SA/IPV at any point in their lives. Respondents who indicated they had previously experienced SA/IPV were directed to questions about how these experiences affected clerkships.

FINDINGS

Of 419 students, 125 responded to the survey (30.8% response rate). Forty (31.1%) reported a history of SA/IPV-32 (80.0%) women, five (12.5%) men, and three (7.5%) who did not report gender or identified as non-binary. Of the 40 respondents with a history of SA/IPV, 20 (50.0%) reported that their prior history affected their overall clinical experience, and nine (22.5%) felt that it affected their performance. Only seven (17.5%) reported using any resources, such as counselling, during their clerkships. Narrative responses discussed significant effects on performing physical exams, taking a history, interacting with team members, and engaging during clerkships.

DISCUSSION

This work demonstrates the high number of students affected by SA/IPV and how these prior experiences affected core components of their clerkship experiences.

CONCLUSIONS

Institutions must be proactive to create better supports for learners with histories of trauma, including SA/IPV.

Carotenoid sequestration protein FIBRILLIN participates in CmOR-regulated β-carotene accumulation in melon

Chromoplasts are plant organelles with a unique ability to sequester and store massive carotenoids. Chromoplasts have been hypothesized to enable high levels of carotenoid accumulation due to enhanced sequestration ability or sequestration substructure formation. However, the regulators that control the substructure component accumulation and substructure formation in chromoplasts remain unknown. In melon (Cucumis melo) fruit, β-carotene accumulation in chromoplasts is governed by ORANGE (OR), a key regulator for carotenoid accumulation in chromoplasts. By using comparative proteomic analysis of a high β-carotene melon variety and its isogenic line low-β mutant that is defective in CmOr with impaired chromoplast formation, we identified carotenoid sequestration protein FIBRILLIN1 (CmFBN1) as differentially expressed. CmFBN1 expresses highly in melon fruit tissue. Overexpression of CmFBN1 in transgenic Arabidopsis (Arabidopsis thaliana) containing ORHis that genetically mimics CmOr significantly enhances carotenoid accumulation, demonstrating its involvement in CmOR-induced carotenoid accumulation. Both in vitro and in vivo evidence showed that CmOR physically interacts with CmFBN1. Such an interaction occurs in plastoglobules and results in promoting CmFBN1 accumulation. CmOR greatly stabilizes CmFBN1, which stimulates plastoglobule proliferation and subsequently carotenoid accumulation in chromoplasts. Our findings show that CmOR directly regulates CmFBN1 protein levels and suggest a fundamental role of CmFBN1 in facilitating plastoglobule proliferation for carotenoid sequestration. This study also reveals an important genetic tool to further enhance OR-induced carotenoid accumulation in chromoplasts in crops.

The potential impact of neighboring states' bans on abortion volume in a haven state

OBJECTIVES

We explored the potential impact of abortion bans in neighboring states on Michigan's abortion volume.

STUDY DESIGN

Using ArcGIS mapping software, we determined which counties in neighboring states had their closest out-of-state abortion clinic in Michigan. We estimated the change in abortions in Michigan occurring from neighboring states' residents, assuming complete bans in those states.

RESULTS

Complete bans in neighboring states could increase abortion volume in Michigan by approximately 5928 out-of-state patients annually (21% increase).

CONCLUSIONS

Complete bans in neighboring states may markedly increase abortions occurring in Michigan, which may strain Michigan facilities' capacity to provide abortion care.

The Impact of New and Renewed Restrictive State Abortion Laws on Pregnancy-Capable People with Diabetes

PURPOSE OF REVIEW

When the Supreme Court handed down its decision in Dobbs v Jackson Women's Health Organization in June 2022, the constitutional right to abortion was no longer protected by Roe v Wade. Fifteen states now have total or near-total bans on abortion care or no clinics providing abortion services. We review how these restrictions affect the medical care of people with pregestational diabetes.

RECENT FINDINGS

Of the ten states with the highest percent of adult women living with diabetes, eight currently have complete or 6-week abortion bans. People with diabetes are at high risk of diabetes-related pregnancy complications and pregnancy-related diabetes complications and are disproportionately burdened by abortion bans. Abortion is an essential part of comprehensive, evidence-based diabetes care, yet no medical society has published guidelines on pregestational diabetes that explicitly discuss the importance and role of safe abortion care. Medical societies enacting standards for diabetes care and clinicians providing diabetes care must advocate for access to abortion to reduce pregnancy-related morbidity and mortality for pregnant people with diabetes.

Trauma-Informed Care Curricula for the Health Professions: A Scoping Review of Best Practices for Design, Implementation, and Evaluation

PURPOSE

Trauma-exposed persons often experience difficulties accessing medical care, remaining engaged in treatment plans, and feeling psychologically safe when receiving care. Trauma-informed care (TIC) is an established framework for health care professionals, but best practices for TIC education remain unclear. To remedy this, the authors conducted a multidisciplinary scoping literature review to discern best practices for the design, implementation, and evaluation of TIC curricula for health care professionals.

METHOD

The research team searched Ovid MEDLINE, Cochrane Library, Elsevier's Scopus, Elsevier's Embase, Web of Science, and the PTSDpubs database from the database inception date until May 14, 2021. Worldwide English language studies on previously implemented TIC curricula for trainees or professionals in health care were included in this review.

RESULTS

Fifty-five studies met the inclusion criteria, with medicine being the most common discipline represented. The most prevalent learning objectives were cultivating skills in screening for trauma and responding to subsequent disclosures (41 studies [74.5%]), defining trauma (34 studies [61.8%]), and understanding trauma's impact on health (33 studies [60.0%]). Fifty-one of the studies included curricular evaluations, with the most common survey items being confidence in TIC skills (38 studies [74.5%]), training content knowledge assessment (25 studies [49.0%]), participant demographic characteristics (21 studies [41.2%]), and attitudes regarding the importance of TIC (19 studies [37.3%]).

CONCLUSIONS

Future curricula should be rooted in cultural humility and an understanding of the impacts of marginalization and oppression on individual and collective experiences of trauma. Moreover, curricula are needed for clinicians in more diverse specialties and across different cadres of care teams. Additional considerations include mandated reporting, medical record documentation, and vicarious trauma experienced by health care professionals.

Universal precautions: the case for consistently trauma-informed reproductive healthcare

In the United States, about 1 in 5 women have experienced childhood sexual abuse, and a similar proportion experience rape as adults. Childhood sexual abuse and other forms of trauma have serious impacts on our patients' reproductive health. The American College of Obstetricians and Gynecologists recommends universal screening for a history of sexual abuse and universal application of a trauma-informed approach to care. Despite these recommendations, universal screening is far from universally practiced, and trauma-informed care, despite being the standard of care, is far from standard. Given the high prevalence of trauma in the United States, its impact on perinatal outcomes, the sensitive nature of reproductive healthcare, and the likelihood that many patients may not disclose their trauma history, we advocate for trauma-informed reproductive healthcare as the standard of care.

Operational Constraints and Gender Biases: A Qualitative Analysis of Physician Parenting Experiences

OBJECTIVE

Although parenting responsibilities are correlated with gender disparities in professional development and salary, the nature of parental challenges is not well characterized. The aims of this study were to (1) illuminate faculty physicians' experiences with parenting and (2) identify system challenges and opportunities for improvement.

MATERIALS AND METHODS

In October 2019, a survey about parenting was sent to all physician faculty at a large Midwest academic medical center. Qualitative analysis of free-text response to the survey item "is there anything you wish to share about your experience of pregnancy or parenting as a physician" was performed. Themes were inductively identified and developed from the responses in a team-based iterative approach.

RESULTS

Of 2069 total physician faculty, 1085 (52.4%) responded to the survey and 253 (23%) of the respondents provided free-text comments. From these comments, the authors identified three themes as sources of challenges for physician parents: operational constraints, gender biases, and nontraditional or nonheteronormative family structures. Operational factors pertained to lack of scheduling flexibility, childcare challenges, lactation, colleague coverage, and transparency of policies. Responses indicated that gender biases are encountered by all genders, and expectations built on assumptions of "traditional" gender roles and family structure are problematic for many physician parents.

CONCLUSION

Addressing the challenges and opportunities identified in the study is critical to building a more supportive institutional culture around parenting and to increase gender parity in academic medicine.

BACE1 Overexpression Reduces SH-SY5Y Cell Viability Through a Mechanism Distinct from Amyloid-β Peptide Accumulation: Beta Prime-Mediated Competitive Depletion of sAβPPα

BACKGROUND

The Alzheimer's disease (AD)-associated amyloid-beta protein precursor (AβPP) can be cleaved by β-site AβPP cleaving enzyme 1 (BACE1) and the γ-secretase complex to yield neurotoxic amyloid-β (Aβ) peptides. However, AβPP can also be cleaved in a 'non-amyloidogenic' manner either by α-secretase to produce soluble AβPP alpha (sAβPPα) (a fragment with neuroprotective/neurogenic functions) or through alternative BACE1-mediated 'beta prime' activity yielding soluble AβPP beta prime (sAβPPβ').

OBJECTIVE

To determine whether sAβPPα depletion, as opposed to Aβ peptide accumulation, contributes to cytotoxicity in AD-relevant SH-SY5Y neuroblastoma cell models.

METHODS

AβPP proteolysis was characterized by immunoblotting in mock-, wild-type AβPP (wtAβPP)-, BACE1-, and Swedish mutant AβPP (SweAβPP)-transfected cells. AβPP beta prime cleavage was confirmed through secretase inhibitor studies and C-terminal fragment analysis. The roles of sAβPPα and sAβPPβ' in cell viability were confirmed by overexpression studies.

RESULTS

Despite producing enhanced Aβ peptide levels, wtAβPP- and SweAβPP-transfected cells did not exhibit reduced viability whereas BACE1-transfected cells did. sAβPPα generation in SH-SY5Y-BACE1 cells was virtually ablated in lieu of BACE1-mediated sAβPPβ' production. sAβPPα overexpression in SH-SY5Y-BACE1 cells restored viability whereas sAβPPβ' overexpression decreased viability further. The anti-AβPP 6E10 antibody was shown to cross-react with sAβPPβ'.

CONCLUSION

sAβPPα depletion and/or sAβPPβ' accumulation, but not elevated Aβ peptide levels, represent the cytotoxic mechanism following BACE1 overexpression in SH-SY5Y cells. These data support the novel concept that competitive sAβPPα depletion by BACE1 beta prime activity might contribute to AD. The cross-reactivity of 6E10 with AβPPβ'also questions whether previous studies assessing sAβPPα as a biomarker using this antibody should be revisited.

The orphan drug dichloroacetate reduces amyloid beta-peptide production whilst promoting non-amyloidogenic proteolysis of the amyloid precursor protein

The amyloid cascade hypothesis proposes that excessive accumulation of amyloid beta-peptides is the initiating event in Alzheimer’s disease. These neurotoxic peptides are generated from the amyloid precursor protein via sequential cleavage by β- and γ-secretases in the ’amyloidogenic’ proteolytic pathway. Alternatively, the amyloid precursor protein can be processed via the ’non-amyloidogenic’ pathway which, through the action of the α-secretase a disintegrin and metalloproteinase (ADAM) 10, both precludes amyloid beta-peptide formation and has the additional benefit of generating a neuroprotective soluble amyloid precursor protein fragment, sAPPα. In the current study, we investigated whether the orphan drug, dichloroacetate, could alter amyloid precursor protein proteolysis. In SH-SY5Y neuroblastoma cells, dichloroacetate enhanced sAPPα generation whilst inhibiting β–secretase processing of endogenous amyloid precursor protein and the subsequent generation of amyloid beta-peptides. Over-expression of the amyloid precursor protein partly ablated the effect of dichloroacetate on amyloidogenic and non-amyloidogenic processing whilst over-expression of the β-secretase only ablated the effect on amyloidogenic processing. Similar enhancement of ADAM-mediated amyloid precursor protein processing by dichloroacetate was observed in unrelated cell lines and the effect was not exclusive to the amyloid precursor protein as an ADAM substrate, as indicated by dichloroacetate-enhanced proteolysis of the Notch ligand, Jagged1. Despite altering proteolysis of the amyloid precursor protein, dichloroacetate did not significantly affect the expression/activity of α-, β- or γ-secretases. In conclusion, dichloroacetate can inhibit amyloidogenic and promote non-amyloidogenic proteolysis of the amyloid precursor protein. Given the small size and blood-brain-barrier permeability of the drug, further research into its mechanism of action with respect to APP proteolysis may lead to the development of therapies for slowing the progression of Alzheimer’s disease.

Integrating reproductive health care into substance use disorder services

People who use drugs face layered stigma and barriers to accessing reproductive health care services. At the same time, they have unique needs for compassionate, trauma-informed, low-barrier reproductive health care. We review the literature on collocated reproductive health care and substance use treatment services in this population and advocate for expansion of reproductive health care services at sites providing care for substance use disorder. Through this review article, we outline the evidence for and best practices in collocating reproductive health care within substance use disorder services.

Confirmation that candidatus Coxiella cheraxi from redclaw crayfish (Cherax quadricarinatus) is a close relative of Coxiella burnetii, the agent of Q-fever

A Coxiella sp. closely related to the agent of Q-fever, Coxiella burnetii, has been associated with mortalities in redclaw crayfish, (Cherax quadricarinatus), in farms and experimental facilities for three decades. Limited sequence data including 16S rRNA have placed the rickettsial species as a new species, candidatus C. cheraxi closely related to C. burnetii. MinION sequencing was conducted on the last remaining sample from an outbreak of disease, TO-98. The accuracy of base pair reads was mostly 99·9% (error rate 1 in 1000) or better. After filtering for reads of co-isolated Citrobacter freundii, 2629 sequences remained with the longest being 12 585 base pairs (bp). The longest 21 sequences are presented with their single best hit statistics when examined by NCBI blastn (nucleotides) and the nucleotides translated into proteins NCBI blastx. All sequences hit with either C. burnetii (29/42, 69%) or Coxiella (10/42, 24%) or rickettsia (3/42, 7%) with an error rate of less than 1 in 1 million for either bp or amino acids. Sequencing in this report confirms candidatus C. cheraxi is a new species very closely related to C. burnetii. SIGNIFICANCE AND IMPACT OF THE STUDY: This work reports on the use of newer technologies on archival samples and provides significantly more data on the currently limited genome data of candidatus Coxiella cheraxi, one of the few species isolated in the genus Coxiella. Candidatus Coxiella cheraxi causes death in redclaw crayfish and has been reported as being closely related to C. burnettii, the agent of Q-fever, based on 16S rRNA sequencing. This work provides confirmation for this claim.

Providing reproductive health services for women who inject drugs: a pilot program

Background

Needle syringe programs (NSPs), a proven harm reduction strategy for people who inject drugs, frequently offer limited healthcare services for their clients. Women who inject drugs face multiple barriers to accessing reproductive health care in traditional settings: personal histories of trauma, judgmental treatment from providers, and competing demands on their time. Our aim was to implement patient-centered reproductive healthcare services at a Seattle NSP.

Methods

We interviewed clients and staff of an NSP in Seattle and staff of other community-based organizations serving women who inject drugs, then used the Consolidated Framework for Implementation Research to code transcripts deductively. Based on our qualitative work, we implemented reproductive health care at the NSP program 1 day per week. We evaluated the implementation by surveying staff and clients and auditing charts over a 9-month period.

Results

Clients and staff (N = 15 for clients, N = 13 for staff) noted a high unmet need for trauma-informed, accessible reproductive health care. We successfully implemented reproductive health care services including short- and long-acting contraception, sexually transmitted disease testing, and cervical cancer screening. Survey data was limited but demonstrated client satisfaction with services.

Conclusions

Integrating reproductive health care into an NSP’s clinical services is feasible and can be a source of low-barrier preventive care for women unable to seek gynecologic care elsewhere.

Reproductive Health Care Utilization by Women Who Inject Drugs and Exchange Sex in the Seattle Area

Few data exist regarding reproductive health needs of women who inject drugs (WWID) and exchange sex. This group is at increased risk of unintended pregnancy and sexually transmitted infections (STI). They also face stigma and other barriers to accessing reproductive health care. Purpose: To evaluate contraceptive usage, pregnancy intention, and uptake of general and reproductive health services among WWID and exchange sex. Methods: This analysis of the 2016 Seattle area National HIV Behavioral Surveillance survey included women aged 18-49 years who exchanged sex for money or drugs and injected drugs in the last year. We evaluated contraceptive utilization, pregnancy intention, and reproductive health care access. Results: Among 144 respondents meeting inclusion criteria, the median age was 39 (IQR 33-45), the median age at first injection was 22 (IQR 17-28), and the most commonly injected drug was heroin (62.0%). A minority (10.3%) desired pregnancy in the next year. Among women wanting to avoid pregnancy, 65.5% had not used any prescription contraception (pill/patch/ring, injection, intrauterine device, or implant) in the last year. In the last year, nearly all (92.4%) respondents had received health care and over half (59.0%) had had an STI test. Of women eligible for the HPV vaccine, 28.6% had received at least one dose. Conclusions: Most WWID and exchange sex want to avoid pregnancy. Despite accessing health care, a minority are using prescribed contraception. Health care tailored to these women's preferences may reduce unmet contraceptive need and improve access to well-woman care and preconception counseling.

Serological survey of Australian native reptiles for exposure to ranavirus

Ranaviruses have been isolated from many ectothermic vertebrates, and serological surveys of both amphibians and reptiles have shown the presence of ranaviral antibodies in a proportion of these populations. An enzyme-linked immunosorbent assay (ELISA) was developed to measure serum antibodies against ranavirus in Australian reptiles. The ELISA was validated with serum from challenge trials with Bohle iridovirus (BIV) in 6 reptilian species. A preliminary sero-survey of northern Queensland riparian reptile fauna (saw-shelled turtles Myuchelys latisternum, Krefft's river turtles Emydura macquarii krefftii, freshwater crocodiles Crocodylus johnstoni, as well as the snakes Boiga irregularis, Dendrelaphis punctulatus, Tropidonophis mairii, Morelia spilota, Liasis childreni and L. fuscus) revealed evidence of past exposure to Bohle iridoviral antigens in part of the population at several locations sampled. Furthermore, in Krefft's river turtles and freshwater crocodiles, a statistically significant trend was apparent for larger reptiles to be more likely to have BIV-reactive sera than smaller individuals. The use of adult tortoise populations as sentinels can assist in monitoring the presence of BIV in northern Australian freshwater streams, and thereby the potential dangers to native fauna from this agent.

A multidisciplinary team (MDT) approach to managing alcohol-dependent patients with comorbid depression in an acute hospital setting

Introduction

Alcohol-dependent patients have a significantly increased risk of depression, contributing a cycle of relapse and attendance at acute hospital services seeking help. Care is often focused on the alcohol dependence treatment with little consideration of concomitant psychiatric disorders.

Aim

To help bridge this gap in care planning and aim toward multidisciplinary long-term support.

Method

We collected data on all patients referred to our alcohol complex patient MDT. We investigated the range of disciplines involved in patient care. We spoke to our patients about why they had chosen to attend hospital. We then developed a referral system to our alcohol MDT where a bespoke pathways of care was developed with all current and future care providers.

Results

Our patients were often being cared for by multiple services, however much of this work was happening in isolation and was at times conflicting. Importantly, the patients were unclear where to go for what, and were utilizing the ED as a fail-safe when they were troubled.

Of 15 patients referred to MDT, 7 (50%) had a diagnosis of depression (DSM-IV). These patients had an average of 5.1 hospital attendances and 2.2 hospital admissions in the 3 months prior to MDT. At 3 months post-MDT, we were able to demonstrate a reduction in hospital admissions and attendances (average 2.2 & 1.4, respectively).

Conclusions

An MDT for alcohol-dependent patients with depression facilitates effective and collaborative working for the benefit of patients and services.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Mosquito cells (C6/36) fail to support the complete replication of Penaeus merguiensis hepandensovirus

Mosquito cell lines (C6/36) were reported in the literature to support the propagation of Penaeus monodon hepandensovirus (PmoHDV). We aim to evaluate the susceptibility and viral propagation of P. merguiensis hepandensovirus (PmeHDV) which is ∼22% different to PmoHDV in Aedes albopictus cell line (C6/36). Cellular changes in the infected cell culture were detected. Vacuole formation was seen in both infected and uninfected cell cultures. The average number of disrupted cellular membranes in the infected cells (presumptive dead cells) was significantly higher than that of uninfected cells at passage two (F=9.749, d.f. 1, 22, p<0.05). Using a proliferation assay, light absorption of infected cells peaked at 2weeks post-infection (O.D.=0.27) but was significantly lower than that of the uninfected groups (O.D.=0.37) (F=6.879, d.f. 1, 94, p<0.05) suggesting hindered cell growth. PCR of the serial passages of the infected cell cultures indicated weak positive results for PmeHDV infection and TaqMan quantitative PCR confirmed that the average number of viral copies declined from 3.8×10⁵ to 5.69×10² copies per μL and the mean of cycle times increased from 19.26 to 27.63. These results are interpreted to mean C6/36 allows the initial stage of PmeHDV replication, but the virus was incapable of using C6/36 for patent replication of its' virions.

Pathogenicity in six Australian reptile species following experimental inoculation with Bohle iridovirus

Ranaviruses are able to infect multiple species of fish, amphibian and reptile, and some strains are capable of interclass transmission. These numerous potential carriers and reservoir species compound efforts to control and contain infections in cultured and wild populations, and a comprehensive knowledge of susceptible species and life stage is necessary to inform such processes. Here we report on the challenge of 6 water-associated reptiles with Bohle iridovirus (BIV) to investigate its potential pathogenicity in common native reptiles of the aquatic and riparian fauna of northern Queensland, Australia. Adult tortoises Elseya latisternum and Emydura krefftii, snakes Boiga irregularis, Dendrelaphis punctulatus and Amphiesma mairii, and yearling crocodiles Crocodylus johnstoni were exposed via intracoelomic inoculation or co-habitation with infected con-specifics, but none were adversely affected by the challenge conditions applied here. Bohle iridovirus was found to be extremely virulent in hatchling tortoises E. latisternum and E. krefftii via intracoelomic challenge, as demonstrated by distinct lesions in multiple organs associated with specific immunohistochemistry staining and a lethal outcome (10/17) of the challenge. Virus was re-isolated from 2/5 E. latisternum, 4/12 E. krefftii and 1/3 brown tree snakes B. irregularis. Focal necrosis, haemorrhage and infiltration of granulocytes were frequently observed histologically in the pancreas, liver and sub-mucosa of the intestine of challenged tortoise hatchlings. Immunohistochemistry demonstrated the presence of ranavirus antigens in the necrotic lesions and in individual cells of the vascular endothelium, the connective tissue and in granulocytes associated with necrosis or present along serosal surfaces. The outcome of this study confirms hatchling tortoises are susceptible to BIV, thereby adding Australian reptiles to the host range of ranaviruses. Additionally, given that BIV was originally isolated from an amphibian, our study provides additional evidence that interclass transmission of ranavirus may occur in the wild.

Delivering a "dose of hope": a faith-based program to increase older african americans' participation in clinical trials

BACKGROUND

Underrepresentation of older-age racial and ethnic minorities in clinical research is a significant barrier to health in the United States, as it impedes medical research advancement of effective preventive and therapeutic strategies.

OBJECTIVE

The objective of the study was to develop and test the feasibility of a community-developed faith-based intervention and evaluate its potential to increase the number of older African Americans in clinical research.

METHODS

Using a cluster-randomized design, we worked with six matched churches to enroll at least 210 persons. We provided those in the intervention group churches with three educational sessions on the role of clinical trials in addressing health disparity topics, and those in the comparison group completed surveys at the same timepoints. All persons enrolled in the study received ongoing information via newsletters and direct outreach on an array of clinical studies seeking participants. We evaluated the short-, mid-, and longer-term effects of the interventional program on clinical trial-related outcomes (ie, screening and enrollment).

RESULTS

From 2012 to 2013, we enrolled a balanced cohort of 221 persons in the program. At a 3-month follow-up, mean intention to seek information about clinical trials was higher than baseline in both treatment (mu=7.5/10; sigma=3.1) and control arms (mu=6.6/10; sigma=3.3), with the difference more pronounced in the treatment arm. The program demonstrated strong retention at 3-month (95.4%, 211/221) and 6-month timepoints (94.1%, 208/221).

CONCLUSIONS

The "Dose of Hope" program addressed an unmet need to reach an often overlooked audience of older African Americans who are members of churches and stimulate their interest in clinical trial participation. The program demonstrated its appeal in the delivery of effective messages and information about health disparities, and the role of clinical research in addressing these challenges.

Pre-departure preparation for international clinical work: a handbook

International clinical experiences are increasingly popular among medical students, residents, fellows, and practitioners. Adequate pre-departure training is an integral part of a meaningful, productive, and safe international experience. At Johns Hopkins University School of Medicine, we have developed a pre-departure handbook to assist practitioners in preparing for global health work. The handbook draws from current global health education literature, existing handbooks, and expert experiences, and includes information about logistical and cultural preparations. While a pre-departure handbook cannot serve as a substitute for a comprehensive pre-departure training program, it can be a useful introduction to the pre-departure process.

The state of routine and emergency obstetric and neonatal care in Southern Province, Zambia

OBJECTIVE

To evaluate the capacity of health facilities in Southern Province, Zambia, to perform routine obstetric care and emergency obstetric and neonatal care (EmONC).

METHODS

Surveys were completed at 90 health centers and 10 hospitals between September 1, 2011, and February 28, 2012. An expanded set of signal functions for routine care and EmONC was used to assess the facilities' capacity to provide obstetric and neonatal care.

RESULTS

Interviews were completed with 172 health workers. Comprehensive EmONC was available in only six of 10 hospitals; the remaining four hospitals did not perform all basic EmONC signal functions. None of the 90 health centers performed the basic set of EmONC signal functions. Performance of routine obstetric care functions, health worker EmONC training, and facility infrastructure and staffing varied.

CONCLUSION

Assessment of the indicators for routine care revealed that several low-cost interventions are currently underused in Southern Province. There is substantial room for improvement in emergency and routine obstetric and neonatal care at the surveyed facilities. Efforts should focus on improving infrastructure and supplies, EmONC training, and adherence to the UN guidelines for routine and emergency obstetric care.

Induction and characterization of lysogenic bacteriophages from Streptococcus iniae

AIMS

To investigate the presence of prophage in Streptococcus iniae, a highly problematic fish pathogen.

METHODS AND RESULTS

Cross-spotting assays and mitomycin C inductions were conducted to screen for prophage in 48 Strep. iniae isolates. Bacteriophages were characterized by plaque assays, transmission electron microscopy and DNA restriction enzyme digestion. Plaque assays confirmed prophages in 14·6% of isolates. Phages vB_SinS-44, vB_SinS-45, vB_SinS-46 and vB_SinS-48 lysed 78·5% of Strep. iniae isolates and displayed distinctive host ranges. Microscopy revealed virions exhibiting long, non-contractile tails and isometric heads consistent with phages from the family Siphoviridae. Restriction digests revealed genome sizes ranging from 27·5 to 66·3 kbp, with distinct cutting patterns that indicate the presence of related prophages in bacteria isolated from different geographic regions.

CONCLUSIONS

The rate of prophage carriage found is comparably low and induction rates varied between phages. The four characterized Siphoviridae phages have broad host ranges within the Strep. iniae isolates.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first description and characterization of lysogenic phages from Strep. iniae. These phages are candidates for research and diagnosis of the bacterium and their identification should accelerate the discovery of lytic phages to be trialled against Strep. iniae infections in fish.

Non-permissive C6/36 cell culture for the Australian isolate of Macrobrachium rosenbergii nodavirus

Macrobrachium rosenbergii nodavirus (MrNV) that causes white tail disease (WTD) is an emerging disease that contributes to serious production losses in Macrobrachium hatcheries worldwide. Mosquito cell lines (C6/36) have been reported to support the growth of MrNV and used to observe the cytopathic effects (CPE) in infected cells. This study determined the susceptibility of C6/36 mosquito cells to the Australian isolate of MrNV in order to use fewer animals in further investigations. Different staining methods were used to observe MrNV viral activity in C6/36 cells. Typical cytopathic effects such as vacuolation and viral inclusion bodies were observed in infected C6/36 cells with H&E and Giemsa staining. With acridine orange, it was easier to detect presumptive MrNV messenger ribonucleic acid in the infected cells. Using neutral red staining to measure mitochondrial activity showed light absorption of infected cells maximized at day 4 (O.D. = 0.6) but was significantly lower (chi-square = 41.265, df = 1, P < 0.05) than control groups (O.D. = 2) which maximized at day 12. Using trypan blue staining to count the number of cells with disrupted cell membranes, the maximum number of presumptively dead cells at day 8 (4 × 10(5)  cells) in infected treatments was higher than the control treatment at day 10 (1.8 × 10(5)  cells). However, TaqMan real-time PCR did not confirm the replication of MrNV in the cells over 14 days. The mean viral copies and mean cycle times of positive samples were stable at 2.07 × 10(4) and 24.12, respectively. Limited evidence of viral replication was observed during four serial passages. This study determined the mortality of the C6/36 cell line to the Australian isolate of MrNV but suggests limited patent replication was occurring. Trying different cell lines or adapting the virus to the C6/36 cells may be necessary to successfully replicate Australian MrNV in cell lines.

The impact of travel distance on the decision to attend for screening for gestational diabetes mellitus

This paper estimates the impact of travel distance on the decision to attend for screening for gestational diabetes mellitus (GDM), controlling for a range of personal, clinical and lifestyle characteristics. The results suggest that women who live further away from a screening site are less likely to attend for screening. In particular, the probability of attending for screening is reduced by 1.8% [95% CI: 1.2% to 2.4%] for every additional 10 kms of travel. This is consistent wth previous research that shows geographic inequalities in access to GDM screening in Ireland. We also find that older women, those with a family history of diabetes, and those who are obese are more likely to accept the screening offer, suggesting that certain higher-risk groups may be either self-selecting into the screening programme or are being targeted by health care professionals through specific initiatives.

Is there a socioeconomic gradient in the prevalence of gestational diabetes mellitus?

Previous studies have shown an association between Type 2 diabetes and lower socioeconomic status. This link is less clear in those with gestational diabetes mellitus (GDM). We test for a socioeconomic gradient in the prevalence of GDM by analysing data on 9,842 pregnant women who were offered testing for GDM in the Atlantic Diabetes in Pregnancy universal screening programme. A bivariate probit model relating GDM prevalence to socioeconomic status was estimated, controlling for variation in screening uptake rates across socioeconomic groups. The estimated increased prevalence of GDM is 8.6% [95% CI 2.7%-12.0%] for women in the lowest socioeconomic group when compared to the highest, suggesting a strong socioeconomic gradient in the prevalence of GDM. This gradient is found to be driven by differences in personal, clinical and lifestyle factors across socioeconomic groups.

Trimester-specific reference intervals for IFCC standardised haemoglobin A(1c): new criterion to diagnose gestational diabetes mellitus (GDM)?

We established trimester-specific reference intervals for IFCC standardised HbA(1c) in 311 non-diabetic Caucasian pregnant women (n = 246) and non-pregnant women (n = 65). A selective screening strategy based on risk factors for gestational diabetes was employed. Pregnancy trimester was defined as trimester 1 (T1, n = 40) up to 12 weeks + 6 days, trimester 2 (T2, n = 106) 13 to 27 weeks + 6 days, trimester 3 (T3, n = 100) > 28 weeks to delivery. The normal HbA(1c) reference interval for Caucasian non-pregnant women was 29-37 mmol/mol (DCCT: 4.8-5.5%), T1: 24-36 mmol/mol (DCCT: 4.3-5.4%), T2: 25-35 mmol/mol (DCCT: 4.4-5.4%), and T3: 28-39 mmol/mol (DCCT: 4.7-5.7%). HbA(1c) was significantly decreased in trimesters 1 (P < 0.01) and 2 (P < 0.001) compared to non-pregnant women. Retrospective application of selective screening to Caucasian women of the Atlantic DIP cohort determined that 5,208 met the criteria. 945 of those women (18.1%) were diagnosed with Gestational Diabetes Mellitus (GDM) using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) glucose concentration thresholds. HbA(1c) measurement within 2 weeks of the diagnostic Oral Glucose Tolerance Test (OGTT) was available in 622 of 945 (66%). Applying the decision threshold for T2: HbA(1c) > 35 mmol/mol (DCCT > 5.4%) identified 287 of 622 (46%) of those with GDM. HbA(1c) measurement in T2 (13 to 27 weeks) should be included in the diagnostic armamentarium for GDM. This would reduce the need for diagnostic OGTT in a significant number of women.

Psychological stress associated with diabetes during pregnancy: a pilot study

Gestational Diabetes Mellitus (GDM) affects approximately 12% of women. The impact of a diagnosis of GDM may lead to increased stress in pregnancy due to the demands of adherence to a treatment regimen and maternal concern about adverse outcomes for the mother and baby. We examined the psychosocial profile of 25 women with gestational diabetes mellitus (GDM) and compared them to 25 non-diabetic pregnant women. Measures administered included the Pregnancy Experiences Scale (PES), the Depression, Anxiety Stress Scale (DASS), the Problem Areas in Diabetes Scale (PAID-5) and the Perceived Social Support Scale (PSSS). The GDM group reported a significantly greater ratio of pregnancy 'hassles' to pregnancy 'uplifts'. The GDM group also had a significantly higher Depression score and were twice as likely to score above the cut-off for possible depression. Elevated levels of diabetes-related distress were found in 40% of women with GDM. In addition, the GDM group reported less social support from outside the family. Our preliminary study indicates that the experience of GDM appears to be associated with increased psychological distress in comparison to the experience of non-diabetic pregnant women. This may indicate the need for psychological screening in GDM and the provision of psychological support in some cases.

Injection of Acanthaster planci with thiosulfate-citrate-bile-sucrose agar (TCBS). II. Histopathological changes

We assessed histological changes in the tissues of the crown-of-thorns starfish Acanthaster planci (COTS) after injection of thiosulfate-citrate-bile-sucrose agar (TCBS) which was used as a disease inducer (potential outbreak control method), by conventional and scanning electron microscopy. Digestive glands were processed and stained with hematoxylin and eosin to describe the histological architecture of the intestinal epithelium. Subsequently comparison of healthy versus infected tissues and Gram stains were carried out to confirm bacterial occurrence on infected tissues, characterize the structural changes induced by bacterial communities in COTS tissues, and to determine if the histopathological changes of intestinal tissues were consistent with vibrio infection. TCBS injections induced marked epithelial desquamation, hypertrophy and hypersecretion of glandular cells, epithelial cell destruction, pyknosis, reduction of thickness and disorganization of connective tissue and associated nerve plexus, presence of bacterial colonies, irregular eosinophilic foci in glandular cells, brush border disruption, atrophy and detachment of intestinal microvilli and cell debris in the lumen. All these changes were attributed to a fulminating systemic dysbiosis and were consistent with vibrio infections.

Injection of Acanthaster planci with thiosulfate-citrate-bile-sucrose agar (TCBS). I. Disease induction

This is the first report of the successful induction of a transmissible disease in the coral-eating crown-of-thorns starfish Acanthaster planci (COTS). Injection of thiosulfate-citrate-bile-sucrose agar (TCBS) culture medium into COTS induced a disease characterized by discoloured and necrotic skin, ulcerations, loss of body turgor, accumulation of colourless mucus on many spines especially at their tip, and loss of spines. Blisters on the dorsal integument broke through the skin surface and resulted in large, open sores that exposed the internal organs. Oedema and reddened digestive tissues and destruction of connective fibers were common. Moreover, healthy COTS in contact with these infected animals also displayed signs of disease and died within 24 h. TCBS induced 100% mortality in injected starfish. There was no introduction of new pathogens into the marine environment. TCBS promoted the growth of COTS' naturally occurring Vibrionales to high densities with subsequent symbiont imbalance followed by disease and death.

Refined identification of Vibrio bacterial flora from Acanthasther planci based on biochemical profiling and analysis of housekeeping genes

We used a polyphasic approach for precise identification of bacterial flora (Vibrionaceae) isolated from crown-of-thorns starfish (COTS) from Lizard Island (Great Barrier Reef, Australia) and Guam (U.S.A., Western Pacific Ocean). Previous 16S rRNA gene phylogenetic analysis was useful to allocate and identify isolates within the Photobacterium, Splendidus and Harveyi clades but failed in the identification of Vibrio harveyi-like isolates. Species of the V harveyi group have almost indistinguishable phenotypes and genotypes, and thus, identification by standard biochemical tests and 16S rRNA gene analysis is commonly inaccurate. Biochemical profiling and sequence analysis of additional topA and mreB housekeeping genes were carried out for definitive identification of 19 bacterial isolates recovered from sick and wild COTS. For 8 isolates, biochemical profiles and topA and mreB gene sequence alignments with the closest relatives (GenBank) confirmed previous 16S rRNA-based identification: V. fortis and Photobacterium eurosenbergii species (from wild COTS), and V natriegens (from diseased COTS). Further phylogenetic analysis based on topA and mreB concatenated sequences served to identify the remaining 11 V harveyi-like isolates: V. owensii and V. rotiferianus (from wild COTS), and V. owensii, V. rotiferianus, and V. harveyi (from diseased COTS). This study further confirms the reliability of topA-mreB gene sequence analysis for identification of these close species, and it reveals a wider distribution range of the potentially pathogenic V. harveyi group.

The effect of Penaeus merguiensis densovirus on Penaeus merguiensis production in Queensland, Australia

Penaeus merguiensis densovirus (PmergDNV) is currently present on several Queensland prawn farms culturing Penaeus merguiensis. Densoviruses have been linked to mortality and stunting that has caused significant financial loss to prawn farms in Asia. A histopathological study for PmergDNV was initially undertaken to compare broodstock to grow out factors from 60 broodstock animals from each of 22 ponds. There was a significant negative correlation (r = -0.61) between the number of animals with PmergDNV lesions and healthy animals. Furthermore, a higher number of septic hepatopancreatic tubules was correlated (r = 0.48) to high PmergDNV loads. Hence, a polymerase chain reaction analysis of 10-day-old post-larvae (PL) was conducted to determine whether PmergDNV infection was resulting in production losses. An attributable risk analysis of PL from 190 ponds over a 2-year period revealed that 28-29% of ponds with below average survival will have at least average survival following the removal of or decreased levels of PmergDNV. P. merguiensis culture facilities in Queensland should have at least a 14.5% increase in production, equating to an increase of $2.25 million within the first year alone, following the removal or reduction of PmergDNV in their ponds. Hence, focussing efforts on prevention, better management practices and maintaining healthy stock should be of top priority.

Gill-associated virus and its association with decreased production of Penaeus monodon in Australian prawn farms

Gill-associated virus (GAV) was found to be associated with decreased prawn, Penaeus monodon, production when prawns from three farms (n = 45 ponds, 1800 prawns) were monitored for GAV over the production season using a graded RT-nPCR. The grading system used was a visualization of either the outer or inner nested PCR products. Prevalence and loading of GAV were associated with disease severity. Ponds with a higher initial prevalence and a larger increase in GAV load over the production period suffered disease outbreaks. Ponds with low initial prevalence of GAV but a larger increase in prevalence and large increase in load over the production period suffered chronic disease with no disease outbreak identified, yet low production. However, the ponds with moderate to low initial prevalence of GAV with a low increase in prevalence and load of GAV over the production period incurred no disease outbreak and comparatively high production. Ponds with GAV prevalence greater than 75% at 1 month post-stocking should be considered for termination as they have a high probability (95%) of having a disease outbreak. Emergency harvest when a disease outbreak occurs will significantly limit mortality losses.

Insight into the lymphoid organ of penaeid prawns: a review

In crustacea, the lymphoid organ (LO) is found exclusively in penaeid prawns. Other crustaceans such as crabs, lobsters and crayfish do not possess lymphoid organs. Many scientists believe that the lymphoid organ is involved in defence against invading pathogens. The discovery of immune-related genes with the LO confirms some cells have immunological roles even though these genes might be from the haemocytes within this organ. The formation of the lymphoid organ spheroid (LOS) cells has been observed in many naturally or experimentally infected penaeid prawns with viral diseases. It has been suggested that these spheroid cells constitute a major site of viral degradation. The origin and elimination mechanism of the spheroids has been debated in a number of publications. It is most likely that this cell type is produced from exocytosed granular haemocytes and eliminated to the environment rather than in situ destruction via necrosis or apoptosis.

Isolation of lytic bacteriophage against Vibrio harveyi

AIMS

The isolation of lytic bacteriophage of Vibrio harveyi with potential for phage therapy of bacterial pathogens of phyllosoma larvae from the tropical rock lobster Panulirus ornatus.

METHODS AND RESULTS

Water samples from discharge channels and grow-out ponds of a prawn farm in northeastern Australia were enriched for 24 h in a broth containing four V. harveyi strains. The bacteriophage-enriched filtrates were spotted onto bacterial lawns demonstrating that the bacteriophage host range for the samples included strains of V. harveyi, Vibrio campbellii, Vibrio rotiferianus, Vibrio parahaemolyticus and Vibrio proteolyticus. Bacteriophage were isolated from eight enriched samples through triple plaque purification. The host range of purified phage included V. harveyi, V. campbellii, V. rotiferianus and V. parahaemolyticus. Transmission electron microscope examination revealed that six purified phage belonged to the family Siphoviridae, whilst two belonged to the family Myoviridae. The Myoviridae appeared to induce bacteriocin production in a limited number of host bacterial strains, suggesting that they were lysogenic rather than lytic. A purified Siphoviridae phage could delay the entry of a broth culture of V. harveyi strain 12 into exponential growth, but could not prevent the overall growth of the bacterial strain.

CONCLUSIONS

Bacteriophage with lytic activity against V. harveyi were isolated from prawn farm samples. Purified phage of the family Siphoviridae had a clear lytic ability and no apparent transducing properties, indicating they are appropriate for phage therapy. Phage resistance is potentially a major constraint to the use of phage therapy in aquaculture as bacteria are not completely eliminated.

SIGNIFICANCE AND IMPACT OF THE STUDY

Phage therapy is emerging as a potential antibacterial agent that can be used to control pathogenic bacteria in aquaculture systems. The development of phage therapy for aquaculture requires initial isolation and determination of the bacteriophage host range, with subsequent creation of suitable phage cocktails.

Evidence for the classification of a crayfish pathogen as a member of the genus Coxiella

AIMS

The study aimed to provide characterization of a potential new species of Coxiella, identified following a series of outbreaks of disease in Australian native freshwater crayfish.

METHODS AND RESULTS

PCR primers designed for amplification of Coxiella burnetii genes including 16S rDNA, com1 and sodB were used to amplify homologues in the Coxiella-like crayfish pathogen. Products were then cloned and sequenced. The organism demonstrated a high degree of sequence homology in the highly conserved 16S rDNA (96%) and sodB (99%) genes, as well as the Coxiella sp. specific com1 (100%) gene. Regions flanking the sodB coding sequence demonstrated homology to C. burnetii antioxidant AhpC/Tsa family protein and dihydrodipicolinate reductase gene.

CONCLUSIONS

The degree of homology between the genes selected and flanking regions suggested the two organisms were sufficiently closely related to belong to the same genus.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study provided evidence for a potential new species in the currently monospecific genus Coxiella, with the only described member being C. burnetii, a category B biological warfare agent.

Sensitivity and specificity of current diagnostic tests for gill-associated virus in Penaeus monodon

This study reports the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy between a reverse transcriptase-nested polymerase chain reaction (RT-nPCR) and an enzyme-linked immunosorbent assay (ELISA) for the detection of gill-associated virus (GAV) from a sample of 120 Penaeus monodon. Subsequently, the same comparisons were applied to the ELISA and haemagglutination (HA) assays for detection of GAV from a second 120 prawns. The optical density (OD) or dilution cut-off point had a direct influence on the tested parameters. The cut-off OD of 0.5-0.6 with the ELISA produced a sensitivity of 98% compared with RT-nPCR. However, these OD produced the lowest accuracy (85.8% and 86.7%, respectively). The OD cut off of 0.75 resulted in the highest accuracy (91.7%) and NPV (81.3%) while it had the second highest sensitivity (97%) and PPV (93.3%). However, the OD cut off of 0.9 had the highest specificity (80%). With regards to HA, the titre cut off at 8 resulted in the highest sensitivity, specificity and NPV (94%, 100% and 100%, respectively) compared with the ELISA, while the HA titre of 16 gave the highest accuracy (73%) and the second highest specificity (75%). A HA titre of 64 gave the highest PPV (81%). Using the RT-nPCR as the gold standard, the ELISA had an accuracy of 91.7% when using a cut off >0.75 as a positive result. When compared with the ELISA, the HA had an accuracy of 73% when using an HA titre cut off greater than 16 as a positive result. These results indicate that alternative tests for GAV (ELISA and HA) can be used to explore multiple questions about the disease status of P. monodon stocks in a cost-effective manner.

Changes to the phenotypic profile of Vibrio harveyi when infected with the Vibrio harveyi myovirus-like (VHML) bacteriophage

AIMS

To determine if infection of Vibrio harveyi with the V. harveyi myovirus-like (VHML) bacteriophage causes a change to the phenotypic profile of this species.

METHODS AND RESULTS

Using 46 biochemical and metabolic tests, phenotypic profiles for noninfected V. harveyi and VHML infected V. harveyi were developed. Comparison of the infected and bacteriophage-infected strains of V. harveyi 645, 20 and 45 were found to have different test results for d-gluconate utilization, gamma-glutamyl transpeptidase and sulfatase activity, respectively. Using probabilistic identification, VHML infected and noninfected strains were identified as V. harveyi and had similar Willcox probability scores though the modal likelihood scores were reduced for VHML infected strains. One VHML infected strain, 642b, was misidentified as V. campbellii by phenotyping but not by PCR. It would appear that the phenotype of V. harveyi strains infected with VHML, are sufficiently altered that they occur at the margins of the known range of strain variation for V. harveyi.

CONCLUSION

Infection of V. harveyi with VHML causes the phenotypic profile of the bacterium to change. This change reduces the modal likelihood score resulting in a poorer level of assurance for an identification of V. harveyi, especially in the natural host, strain 642. The bacteriophage VHML integrates into different sites in different strains of V. harveyi.

SIGNIFICANCE AND IMPACT OF THE STUDY

The identification of V. harveyi as the causative agent of mortality in aquatic organisms is predominantly achieved through phenotyping. Since bacteriophages alter virulence in V. harveyi, understanding the effect they have on phenotype is important.

[Development of a synthetic positive control which also detects plasmid contamination in diagnostic polymerase chain reaction]

This paper describes a technique for the development of a positive control for use in a nested PCR to show that the PCR has worked correctly with both outer and inner primers designed for diagnostic amplification of 618 bp and 317 bp products respectively. This positive control produces a larger product than the diagnostic sample that can be discriminated on an agarose gel. This technique is advantageous over traditional cloning of the diagnostic PCR product itself by: 1) making it visually easy to detect plasmid contamination and thus, prevent false positives from the plasmid; 2) develop a positive control when the target organism is at a very low prevalence so initial detection is not relied on for cloning positive controls. This will ensure the PCR is working correctly prior to diagnostic sampling, reducing false negatives; or 3) for developing a PCR and determining the sensitivity prior to the use of diagnostic samples. The methods used to produce this nested positive control demonstrates how to use large oligonucleotide primers in PCR without non-specific binding occurring.