Presumed tuberculosis-associated uveitis: rising incidence and widening criteria for diagnosis in a non-endemic area

PurposeTo assess the incidence, clinical ocular involvement and effectiveness of anti-tuberculous treatment in patients with chronic uveitis presumed to be associated with tuberculosis in a non-endemic community.Patients and methodsRetrospective case series of patients with uveitis and evidence of tuberculosis, with no other identified cause of uveitis, who underwent a 6-month course of standard anti-tuberculosis treatment between 2008 and 2015. The response to treatment was assessed at 6 and 12 months after initiation of treatment.ResultsForty-eight patients were included of whom 36 (75%) were born outside the United Kingdom. Only five had concurrent active pulmonary or nodal tuberculosis. There were 85 affected eyes, including 25 with granulomatous anterior uveitis, 32 with retinal vasculitis (occlusive in 21), and 20 with multifocal choroiditis or serpiginous-like retinochoroiditis. Gamma-interferon testing was positive in 95%. Complete resolution at end point was seen in only 60%, but a further 19% were inflammation-free on topical steroid only. Resolution was lower (50%) in those with panuveitis compared to other anatomical types (75%). Sixty-four eyes (75%) had a LogMAR visual acuity of 0.1 or better at the end of the study.ConclusionsThe incidence of presumed tuberculosis-associated uveitis (TBU) has almost quadrupled in this region. The efficacy of treatment has not been enhanced by the introduction of gamma-interferon testing to support diagnosis. Some patients may require more prolonged antibiotic therapy to ensure quiescence, but chronic non-infective anterior uveitis may in any case follow treated TBU.

Equitable tuberculosis care in the North West of England: analysis of tuberculosis cohort review data

BACKGROUND: In the United Kingdom, tuberculosis (TB) predominantly affects the most deprived populations, yet the extent to which deprivation affects TB care outcomes is unknown.

METHODS: Since 2011, the North West TB Cohort Audit collaboration has undertaken quarterly reviews of outcomes against consensus-defined care standard indicators for all individuals notified with TB. We investigated associations between adverse TB care outcomes and Index of Multiple Deprivation (IMD) 2010 scores measured at lower super output area of residence using logistic regression models.

RESULTS: Of 1831 individuals notified with TB between 2011 and 2014, 62% (1131/1831) came from the most deprived national quintile areas. In single variable analysis, greater deprivation was significantly associated with increased likelihood of the completion of a standardised risk assessment (OR 2.99, 95%CI 5.27–19.65) and offer of a human immunodeficiency virus test (OR 1.72, 95%CI 1.10–2.62). In multivariable analysis, there were no significant associations.

CONCLUSIONS: TB patients in the most deprived areas had similar care indicators across a range of standards to those of individuals living in the more affluent areas, suggesting that the delivery of TB care in the North West of England is equitable. The extent to which the cohort review process contributes to, and sustains, this standard of care deserves further study.

In-Process R eometry Studies of LDPE Compounds

The second part of a comprehensive study into the investigation and validation of in-process measurements on a low density polyethylene compound during extrusion is reported. A commercial grade of branched low density polyethylene was used in the study, compounded with various levels of magnesium hydroxide ame retardant filler, up to 0 by weight. In-line and on-line rheometry were used to monitor melt ow behaviour during single screw and twin screw extrusion; off-line capillary rheometry was performed on the compound before and after extrusion, to examine any change in rheology. Morphological observations were made using scanning electron microscopy, and molecular characterisations carried out using gel permeation chromatography. In-process rheometry was found to be able to detect the presence of filler at low and high loadings, but was unable to discriminate between intermediate levels. Off-line rheometry indicated that twin screw extrusion altered the rheology of the compound, and capillary wall slip was found to increase after extrusion. Morphological observation indicated that filler in the compound was better dispersed after extrusion, especially at high volume fractions. Molecular weight and polydispersity of the LDPE were shown to increase after extrusion, more so in the case of low filler loadings. Overall, in-process measurements provided useful rheological data, and the compound was found to exhibit complex, process-dependent rheology.

In-Process R eometry Studies of LDPE Compounds

The initial part of a comprehensive study into the investigation and validation of in-process measurements on a low density polyethylene (LDPE) compound during extrusion is reported. An unfilled, commercial grade of low density polyethylene was processed using fully instrumented, computer monitored, single and twin screw extruders in the Interdisciplinary Research Centre (IRC) laboratories, University of Bradford. Three in-process rheometers were used; a prototype Rosand capillary on-line rheometer (OLR), a four sensor slit die in-line rheometer (ILR) and a six sensor slit die ILR. Off-line comparisons were carried out using a Rosand RH twin bore capillary rheometer. All devices allowed shear ow characterisation at a range of processing rates, and the capillary rheometers also provided a measurement of entry pressure drop through the use of orifice dies. The six-sensor ILR also allowed measurement of entry pressure drop into the slit, although the differences in ow geometry meant these measurements were not directly comparable with the capillary devices, and exit pressures were extrapolated from ILR pressure drops. The in-process devices exhibited very good agreement with measurements made off-line, in both shear ow and entry pressures. In-line slit die measurements were very close to those made using capillary dies, despite the in-line tests being non-isothermal and employing a different geometry of measurement section. Differences in melt rheology between single and twin extrusion were observed, due to the amount of mechanical work input by each extruder. Overall, good agreement was observed from the four different routes to measurement, for the LDPE examined.

Sensitivity of In-line Rheometry for Extrusion of Mg(OH)2 filled LDPE Compounds

In-process and off-line rheometry studies are reported for compounds based on Mg(OH)2 filled low density polyethylene, some of which were first subjected to a range of strain histories in typical compounding operations. In the study reported here, the compounds were processed using an instrumented, computer monitored single screw extruder in the IRC laboratories, fitted with in line rheometers (ILR). In initial experiments a four sensor ILR slit die was used for the in-process shear rheometry, and a Rosand RH7 twin bore capillary rheometer for off-line shear and entry pressure measurements. Off line and in-line results are compared, showing good agreement for shear. Estimates have been obtained for the sensitivity to filler loading of the off line rheometer (shear flow and entry pressure measurements), and the 4 sensor ILR (shear flow measurements), which indicate that the ILR offers similar resolution of filler level to the off line rheometer at the higher loadings, although the ILR appears to have much lower sensitivity at higher shear rates at lower loadings, an effect which appears to be related to processing effects on the rheology of the compound rather than the measurement ability of the ILR. The ILR was also able to discriminate between samples with differing processing histories. Results from a six-sensor ILR die have shown good agreement in shear flow measurements, and have added the ability to measure entry pressures, which are compared with off-line measurements.

Guidelines for the management of adult lower respiratory tract infections--summary

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Guidelines for the management of adult lower respiratory tract infections--full version

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Towards an understanding of the nature of resistance to Phytophthora root rot in red raspberry

A mapping population segregating for root rot resistance was screened under both field and glasshouse conditions over a number of seasons. Few correlations between field and glasshouse scores were significant. Final root rot scores were significantly negatively correlated with measures of root vigour. Two QTL associated with resistance were identified as were overlapping QTL for root vigour assessments. Markers significantly associated with the traits were used to identify BAC clones, which were subsequently sequenced to examine gene content. A number of genes were identified including those associated with stem cell identity, cell proliferation and elongation in the root zone, control of meristematic activity and organisation, cell signalling, stress response, sugar sensing and control of gene expression as well as a range of transcription factors including those known to be associated with defence. For marker-assisted breeding, the SSR marker Rub118b 110 bp allele from Latham was found in resistant germplasm but was not found in any of the susceptible germplasm tested.

Presumed tuberculous uveitis: diagnosis, management, and outcome

PURPOSE

To assess the effectiveness of anti-tuberculous treatment in patients with chronic uveitis and either active systemic or latent tuberculosis (TB) in a non-endemic community.

METHODS

Retrospective study of patients with chronic uveitis, non-ocular evidence of latent or active TB and no other identified cause of uveitis who underwent a 6-month course of standard anti-tuberculous chemotherapy. Response to treatment was assessed at 6 and 12 months after initiation of treatment.

RESULTS

A total of 27 patients were included of whom 59% were female. In all, 19 were Asian, 4 Caucasian, and 4 Black. More than half of patients had a history of contact with another person treated for TB. Inflammation resolved after chemotherapy in 70.3% of patients, 18.5% had a change in the nature of their inflammation and 11.1% had no benefit.

CONCLUSIONS

There were no uveitis features characteristic of TB uveitis and a wide range of manifestations was seen ranging from non-granulomatous anterior uveitis to occlusive retinal vasculitis. TB is not endemic in the United Kingdom, therefore consideration of ethnicity, immigration, and history of TB contact remain important to direct investigations. In a patient with uveitis and latent TB, a full 6-month course of anti-tuberculous chemotherapy is recommended although it may not be curative of the uveitis.

Investigation of a tuberculosis cluster at a job centre in Manchester, United Kingdom

During the summer of 2005, four cases of active tuberculosis from the same occupational setting were investigated in Manchester, UK. The index case had been diagnosed in December of the previous year. At that stage the closest occupational contacts had been screened, all of whom were assessed as being free from active disease, and none had met nationally recommended criteria for chemoprophylaxis for latent tuberculosis infection (LTBI). In June 2005, two work contacts developed progressive primary extrapulmonary (pleural) TB. Following a detailed risk assessment, the screening programme was widened to include 137 staff who worked at the job centre (employment agency) where the first four cases had been found. This screening programme was based on tuberculin Mantoux testing, CXR and gamma-interferon testing. Of these 137 contacts screened, one additional person was found to have active disease and six others were offered chemoprophylaxis for LTBI. The isolates from the index case and the first two secondary cases were indistinguishable on VNTR-MIRU (variable number tandem repeat - mycobacterial interspersed repetitive unit) typing at 15 loci. No samples were available for testing from the fourth case of active disease. Management of this incident has benefited from the evolving fields of both genotyping and diagnostic testing for LTBI. However, further research into the epidemiological inferences made through genotyping, as well as the significance of a positive gamma-interferon test in assessing the risk of development of active disease, is still required.

Policy in child labour

The importance of health

Investigation of a tuberculosis cluster at a job centre in Manchester, United Kingdom

During the summer of 2005, four cases of active tuberculosis from the same occupational setting were investigated in Manchester, UK. The index case had been diagnosed in December of the previous year. At that stage the closest occupational contacts had been screened, all of whom were assessed as being free from active disease, and none had met nationally recommended criteria for chemoprophylaxis for latent tuberculosis infection (LTBI). In June 2005, two work contacts developed progressive primary extrapulmonary (pleural) TB. Following a detailed risk assessment, the screening programme was widened to include 137 staff who worked at the job centre (employment agency) where the first four cases had been found. This screening programme was based on tuberculin Mantoux testing, CXR and gamma-interferon testing. Of these 137 contacts screened, one additional person was found to have active disease and six others were offered chemoprophylaxis for LTBI. The isolates from the index case and the first two secondary cases were indistinguishable on VNTR-MIRU (variable number tandem repeat--mycobacterial interspersed repetitive unit) typing at 15 loci. No samples were available for testing from the fourth case of active disease. Management of this incident has benefited from the evolving fields of both genotyping and diagnostic testing for LTBI. However, further research into the epidemiological inferences made through genotyping, as well as the significance of a positive gamma-interferon test in assessing the risk of development of active disease, is still required.

Post-traumatic stress disorder in young people with intellectual disability

BACKGROUND

Post-traumatic stress disorder (PTSD) is common and treatable. There is extensive research on people of average intelligence yet little on individuals with developmental disabilities.

METHODS

We report two people with intellectual disability (ID) who experienced PTSD. The relevance of their developmental difficulties, social and communication profiles, attentional skills, and causes of these, to their presentations is discussed.

RESULTS

Both individuals have fragile X syndrome and severe ID. One has Diagnostic and Statistical Manual - 4th Edition (DSM-IV) autistic disorder; the other DSM-IV attention deficit-hyperactivity disorder. They experienced developmental and psychological regressions, new challenging behaviours and exacerbations of existing ones coincident with emotional trauma. PTSD symptoms and phenomena were identifiable despite intellectual and communicatory impairments.

CONCLUSION

Presentation of PTSD is influenced by degree and cause of ID, social circumstances, social and communicatory skills, nature and timing of traumatic experience and subsequent management. The paucity of literature suggests it is missed frequently in individuals with ID who risk having problems misattributed to other causes with potential for inappropriate interventions.

Comparative analysis of population genetic structure in Athyrium distentifolium (Pteridophyta) using AFLPs and SSRs from anonymous and transcribed gene regions

To examine the performance and information content of different marker systems, comparative assessment of population genetic diversity was undertaken in nine populations of Athyrium distentifolium using nine genomic and 10 expressed sequence tag (EST) microsatellite (SSR) loci, and 265 amplified fragment length polymorphism (AFLP) loci from two primer combinations. In range-wide comparisons (European vs. North American populations), the EST-SSR loci showed more reliable amplification and produced more easily scorable bands than genomic simple sequence repeats (SSRs). Genomic SSRs showed significantly higher levels of allelic diversity than EST-SSRs, but there was a significant correlation in the rank order of population diversities revealed by both marker types. When AFLPs, genomic SSRs, and EST-SSRs are considered, comparisons of different population diversity metrics/markers revealed a mixture of significant and nonsignificant rank-order correlations. However, no hard incongruence was detected (in no pairwise comparison of populations did different marker systems or metrics detect opposingly significant different amounts of variation). Comparable population pairwise estimates of F(ST) were obtained for all marker types, but whilst absolute values for genomic and EST-SSRs were very similar (F(ST) = 0.355 and 0.342, respectively), differentiation was consistently higher for AFLPs in pairwise and global comparisons (global AFLP F(ST) = 0.496). The two AFLP primer combinations outperformed 18 SSR loci in assignment tests and discriminatory power in phenetic cluster analyses. The results from marker comparisons on A. distentifolium are discussed in the context of the few other studies on natural plant populations comparing microsatellite and AFLP variability.

How much effort is required to isolate nuclear microsatellites from plants?

The attributes of codominance, reproducibility and high resolution have all contributed towards the current popularity of nuclear microsatellites as genetic markers in molecular ecological studies. One of their major drawbacks, however, is the development phase required to obtain working primers for a given study species. To facilitate project planning, we have reviewed the literature to quantify the workload involved in isolating nuclear microsatellites from plants. We highlight the attrition of loci at each stage in the process, and the average effort required to obtain 10 working microsatellite primer pairs.

Community-acquired pneumonia in Europe: causative pathogens and resistance patterns

Community-acquired pneumonia (CAP) is a common condition affecting about 1/1,000 of the adult population per year. It occurs when bacteria enter the alveolar spaces of the lung initiating an inflammatory response which leads to the clinical features of cough, sputum production, breathlessness and sometimes chest pain and haemoptysis. At the end of the last century the causal relationship between bacteria and pneumonia was established and many of the early discoveries about the causes of CAP were made in Europe. Some 41 different prospective studies have established that approximately 10 different microbial pathogens regularly cause CAP with occasional cases due to other rarer causes. The frequency of these organisms in Europe is similar in most countries, but there are some geographic differences. Differences in frequency are also apparent according to illness severity. It is generally recognised that Streptococcus pneumoniae is the most important causal bacterium in all countries. A relatively recent development has been the appearance and spread, in some of the common causative bacteria, of resistance to commonly used antibiotics to which they were once sensitive. The frequency of such resistance does vary markedly between European countries. However, published data is often difficult to interpret. The reasons for this are that the frequency of resistance varies according to the age of the patient, the site of the sample, the clinical diagnosis, the use of prior antibiotics and the influence of special groups e.g. those with cystic fibrosis. The impact of in vitro antibiotic resistance on clinical outcome is still poorly understood, but recent studies are helping to clarify this issue and will be discussed.

Management of influenza in patients with asthma or chronic obstructive pulmonary disease

OBJECTIVE

To review the prevention and treatment of influenza in patients with asthma and/or chronic obstructive pulmonary disease (COPD).

DATA SOURCES

Computer-assisted MEDLINE searches for article and manual searches of conference proceedings on influenza, influenza vaccination, rimantadine, amantadine, oseltamivir, zanamivir, asthma, and/or COPD.

STUDY SELECTION

Published articles and pertinent conference abstracts in the areas mentioned in Data sources were selected. Articles included for review were studies conducted on humans.

RESULTS

Annual vaccination against influenza is the currently accepted practice for influenza management in patients with asthma and/or COPD. However, despite the availability and use of vaccination, influenza continues to cause serious morbidity and increased mortality. The management of influenza in at-risk patients with the older antivirals such as amantadine or rimantadine has not been widely accepted because of the rapid emergence of resistant variants, their lack of effect against influenza B, and poor adverse event profile. A new class of influenza antivirals, the neuraminidase inhibitors, has recently become available for the management of influenza. The currently marketed neuraminidase inhibitors are zanamivir and oseltamivir. Clinical studies have shown that these neuraminidase inhibitors are effective for the treatment and chemoprophylaxis of influenza A and B.

CONCLUSIONS

Vaccination against influenza remains the gold standard for the prevention of influenza in patients with asthma and/or COPD. The neuraminidase inhibitors zanamivir and oseltamivir are useful adjuncts to influenza vaccines for the management of influenza in these patients who are at high-risk of developing influenza related complications.

Neuraminidase inhibitors: progress in the management of influenza

Influenza is a serious respiratory illness and represents a significant clinical burden. As well as being debilitating, influenza can often cause complications leading to hospitalisation and death. Prophylaxis by vaccination is the preferred method of disease management, but because influenza viruses are constantly changing their antigenic properties, influenza outbreaks occur regularly as epidemics. Neuraminidase inhibitors are a new class of anti-influenza drugs designed to block influenza virus replication. Two neuraminidase inhibitors, zanamivir and oseltamivir, have been licensed for clinical use in the treatment of influenza. Both drugs significantly reduce the severity and duration of the illness when treatment is started within two days of the onset of symptoms. However, while zanamivir and oseltamivir have apparently similar efficacy, they differ in their modes of delivery and tolerability. Zanamivir is delivered direct to the lungs by inhalation and is well tolerated. Oseltamivir is taken in the form of a pill but has the side-effect of producing nausea and vomiting in some patients. In the absence of a demonstrable difference in efficacy, uptake of the two drugs will depend on evaluation of the relative merits of mode of delivery and tolerability.

Local antibiotic guidelines for adult community-acquired pneumonia (CAP): a survey of UK hospital practice in 1999

We investigated the guidelines in British hospitals for the management of adults admitted with community-acquired pneumonia (CAP). A questionnaire was sent to one consultant respiratory physician in each of the 263 hospitals in the British Thoracic Society (BTS) Directory of Training Posts and Services. Two hundred and thirteen (81%) responses were received: 178 (84%) had written CAP guidelines, of which 123 (69%) printed copies were received. For non-severe CAP a single antibiotic (74% of guidelines-most frequently amoxycillin or ampicillin) was the usual recommendation with the combination of a beta-lactam and a macrolide the second most frequent (24%). The latter combination was recommended for severe CAP in 81% of guidelines. Clostridium difficile-associated diarrhoea had influenced guideline recommendations, or was commented on as a concern, in 18% of responses. Written guidelines for antibiotic therapy in adults with CAP exist in most British hospitals and follow broadly the 1993 BTS guidelines, although combination therapy is used not infrequently for non-severe CAP.