Long COVID in a highly vaccinated but largely unexposed Australian population following the 2022 SARS-CoV-2 Omicron wave: a cross-sectional survey

OBJECTIVE

To estimate the prevalence of long COVID among Western Australian adults, a highly vaccinated population whose first major exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was during the 2022 Omicron wave, and to assess its impact on health service use and return to work or study.

STUDY DESIGN

Follow-up survey (completed online or by telephone).

SETTING, PARTICIPANTS

Adult Western Australians surveyed 90 days after positive SARS-CoV-2 test results (polymerase chain reaction or rapid antigen testing) during 16 July - 3 August 2022 who had consented to follow-up contact for research purposes.

MAIN OUTCOME MEASURES

Proportion of respondents with long COVID (ie, reporting new or ongoing symptoms or health problems, 90 days after positive SARS-CoV-2 test result); proportion with long COVID who sought health care for long COVID-related symptoms two to three months after infection; proportion who reported not fully returning to previous work or study because of long COVID-related symptoms.

RESULTS

Of the 70 876 adults with reported SARS-CoV-2 infections, 24 024 consented to contact (33.9%); after exclusions, 22 744 people were invited to complete the survey, of whom 11 697 (51.4%) provided complete responses. Our case definition for long COVID was satisfied by 2130 respondents (18.2%). The risk of long COVID was greater for women (v men: adjusted risk ratio [aRR], 1.5; 95% confidence interval [CI], 1.4-1.6) and for people aged 50-69 years (v 18-29 years: aRR, 1.6; 95% CI, 1.4-1.9) or with pre-existing health conditions (aRR, 1.5; 95% CI, 1.4-1.7), as well as for people who had received two or fewer COVID-19 vaccine doses (v four or more: aRR, 1.4; 95% CI, 1.2-1.8) or three doses (aRR, 1.3; 95% CI, 1.1-1.5). The symptoms most frequently reported by people with long COVID were fatigue (1504, 70.6%) and concentration difficulties (1267, 59.5%). In the month preceding the survey, 814 people had consulted general practitioners (38.2%) and 34 reported being hospitalised (1.6%) with long COVID. Of 1779 respondents with long COVID who had worked or studied before the infection, 318 reported reducing or discontinuing this activity (17.8%).

CONCLUSION

Ninety days after infection with the Omicron SARS-CoV-2 variant, 18.2% of survey respondents reported symptoms consistent with long COVID, of whom 38.7% (7.1% of all survey respondents) sought health care for related health concerns two to three months after the acute infection.

Implications for sequencing of biologic therapy and choice of second anti-TNF in patients with inflammatory bowel disease: results from the IMmunogenicity to Second Anti-TNF therapy (IMSAT) therapeutic drug monitoring study

BACKGROUND

Anti-drug antibodies are associated with treatment failure to anti-TNF agents in patients with inflammatory bowel disease (IBD).

AIM

To assess whether immunogenicity to a patient's first anti-TNF agent would be associated with immunogenicity to the second, irrespective of drug sequence METHODS: We conducted a UK-wide, multicentre, retrospective cohort study to report rates of immunogenicity and treatment failure of second anti-TNF therapies in 1058 patients with IBD who underwent therapeutic drug monitoring for both infliximab and adalimumab. The primary outcome was immunogenicity to the second anti-TNF agent, defined at any timepoint as an anti-TNF antibody concentration ≥9 AU/ml for infliximab and ≥6 AU/ml for adalimumab.

RESULTS

In patients treated with infliximab and then adalimumab, those who developed antibodies to infliximab were more likely to develop antibodies to adalimumab, than patients who did not develop antibodies to infliximab (OR 1.99, 95%CI 1.27-3.20, p = 0.002). Similarly, in patients treated with adalimumab and then infliximab, immunogenicity to adalimumab was associated with subsequent immunogenicity to infliximab (OR 2.63, 95%CI 1.46-4.80, p < 0.001). For each 10-fold increase in anti-infliximab and anti-adalimumab antibody concentration, the odds of subsequently developing antibodies to adalimumab and infliximab increased by 1.73 (95% CI 1.38-2.17, p < 0.001) and 1.99 (95%CI 1.34-2.99, p < 0.001), respectively. Patients who developed immunogenicity with undetectable drug levels to infliximab were more likely to develop immunogenicity with undetectable drug levels to adalimumab (OR 2.37, 95% CI 1.39-4.19, p < 0.001). Commencing an immunomodulator at the time of switching to the second anti-TNF was associated with improved drug persistence in patients with immunogenic, but not pharmacodynamic failure.

CONCLUSION

Irrespective of drug sequence, immunogenicity to the first anti-TNF agent was associated with immunogenicity to the second, which was mitigated by the introduction of an immunomodulator in patients with immunogenic, but not pharmacodynamic treatment failure.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

161 Absent in Body But Present in Spirit: Battling on When Both Learners and Faculty are Remote from the Simulation Centre

Over the last year, COVID-19 has constrained the capacity of education centres to deliver face-to-face simulation-based education (SBE). Restrictions on travel between NHS trusts necessitated development of remote simulation to allow learners to participate in training safely. The challenge to maintain training provision was increased due to the imposition of shielding requirements on a member of the education faculty requiring them to isolate at home over a 2-month period (February–April 2021).

The aim of the study was to allow educators isolating at home to continue to support SBE, despite their physical absence from the training centre, by:

Simulating the patient role remotely.

Facilitating debrief from home. Observing SBE within the simulation suite and supporting subsequent discussions using video conferencing platforms.

Supporting delivery of human factors teaching sessions to Trust staff remotely.

To deliver SBE remotely for learners with remote faculty rested on three key requirements:

Collaborative and iterative development of scenarios that could be delivered effectively for learners remotely utilizing expertise from the simulation centres education and technical teams. The creation of scenarios optimized for remote delivery.

Effective communication and observation between remote faculty, centre-based staff and remote participants over Microsoft Teams (MST) to allow remote facilitation of debrief

Controlling and voicing the patient simulator from isolation at home via a desktop PC linked with simulation centre systems via a virtual private network (VPN) and utilizing the Zoom platform.

Faculty member shielding requirements lasted for approximately 8 weeks and during that period they were able to support a range of SBE courses;

Foundation years doctors (supported 14 courses)

Final-year medical students (supported 6 courses)

Surgical nurses (supported 1 course)

Burns speciality (supported 1 course)

Acute care skills: Nurse OSCE provision (supported 4 courses)

Human Factors teaching to trust staff (delivered 5 lectures)

Key equipment:

PC with dual screens to allow MST and Zoom software to be managed simultaneously to allow response to participant communication and interactions in real time.

Headset-Microphone to support effective fidelity within audio exchanges.

The facility to contribute to educational provision was mutually advantageous to all members of the educational faculty:

Off-loading some of the burden of training from those within the centre.

A positive influence on the mental health for the isolated.

Making remote simulation work possible was through whole team collaborative working.

53 Remote and Back Again: An Educator’s Tale of Simulation

Between November 2020 and May 2021, 61 simulation sessions were run either face-to-face or remotely for foundation-level doctors and pre-registration pharmacists. A total of 346 participants attended. Thirty-three sessions were face-to-face (185 participants) and 28 were remotely via Microsoft Teams (161 participants). The content was the same for both modalities.

The aim of the study was to discern whether there was a difference in learning points and confidence scores between face-to-face and remote participants.

Participants were asked to rate their confidence (see Table 1) before and after the course. They were asked to provide their main learning points and what they gained from the course. Confidence scores were compared and assessed for change. Responses were compared between face-to-face and remote.

Confidence score change on Likert scale 1–5.

All participants reported increased confidence. Table 1 shows that the changes were comparable, with the changes in the remote participants all being marginally higher than in face-to-face. The distribution of learning points for remote and face-to-face participants was identical. For both modalities, the top two points were communication and escalation. The dominant theme in remote was escalation and communication in face-to-face. Remote participants were positive about the course, in their free-text responses, ‘most innovative use of technology I have seen during COVID’ and ‘My hands are sweating, I can’t believe how real that felt’ a common theme in the comments was that they would rather do the course face-to-face.

While not preferred, remote simulation appears to deliver equivalent learning and is a suitable alternative when face-to-face is impossible. The main difference seen was in communication skills, which is concurrent with Cheng et al.

Influenza Virus Infects and Depletes Activated Adaptive Immune Responders

Influenza infections cause several million cases of severe respiratory illness, hospitalizations, and hundreds of thousands of deaths globally. Secondary infections are a leading cause of influenza's high morbidity and mortality, and significantly factored into the severity of the 1918, 1968, and 2009 pandemics. Furthermore, there is an increased incidence of other respiratory infections even in vaccinated individuals during influenza season. Putative mechanisms responsible for vaccine failures against influenza as well as other respiratory infections during influenza season are investigated. Peripheral blood mononuclear cells (PBMCs) are used from influenza vaccinated individuals to assess antigen-specific responses to influenza, measles, and varicella. The observations made in humans to a mouse model to unravel the mechanism is confirmed and extended. Infection with influenza virus suppresses an ongoing adaptive response to vaccination against influenza as well as other respiratory pathogens, i.e., Adenovirus and Streptococcus pneumoniae by preferentially infecting and killing activated lymphocytes which express elevated levels of sialic acid receptors. These findings propose a new mechanism for the high incidence of secondary respiratory infections due to bacteria and other viruses as well as vaccine failures to influenza and other respiratory pathogens even in immune individuals due to influenza viral infections.

Influenza virus suppresses the adaptive immune response leaving immune hosts vulnerable to influenza and other respiratory pathogens

Influenza infections are associated with several million cases of severe respiratory illness, hospitalizations, and hundreds of thousands of deaths globally. Secondary infections further complicate influenza’s high morbidity and mortality, and significantly factored into the severity of the 1918, 1968, and 2009 pandemics. The most common coinfections are bacterial, leading to bacterial pneumonia, though viral secondary infections also occur. Previous studies have shown that influenza can target innate responses and damage affected tissues, allowing for secondary infections. In this study we show that influenza virus targets not only innate immune responses but also the adaptive responses - specifically activated B cells, T cells, and NKT cells. Importantly, we demonstrate that infection with influenza virus can attenuate the adaptive responses to prior influenza vaccination and to other respiratory pathogen vaccinations, in humans and in mouse models. This occurs through a viral hijacking of the normal immune responses by taking advantage of elevated expression of sialic acid receptors on activated lymphocytes to preferentially infect and kill immune responders. Our findings provide a novel potential mechanism for the high incidence of secondary respiratory infections due to bacteria and other viruses, as well as for vaccine failures against other infectious agents during influenza seasons.

Using high-frequency phosphorus monitoring for water quality management: a case study of the upper River Itchen, UK

Increased concentrations of phosphorus (P) in riverine systems lead to eutrophication and can contribute to other environmental effects. Chalk rivers are known to be particularly sensitive to elevated P levels. We used high-frequency (daily) automatic water sampling at five distinct locations in the upper River Itchen (Hampshire, UK) between May 2016 and June 2017 to identify the main P species (including filterable reactive phosphorus, total filterable phosphorus, total phosphorus and total particulate phosphorus) present and how these varied temporally. Our filterable reactive phosphorus (considered the biologically available fraction) data were compared with the available Environment Agency total reactive phosphorus (TRP) values over the same sampling period. Over the trial, the profiles of the P fractions were complex; the major fraction was total particulate phosphorus with the mean percentage value ranging between 69 and 82% of the total P present. Sources were likely to be attributable to wash off from agricultural activities. At all sites, the FRP and Environment Agency TRP mean concentrations over the study were comparable. However, there were a number of extended time periods (1 to 2 weeks) where the mean FRP concentration (e.g. 0.62 mg L^-1) exceeded the existing regulatory values (giving a poor ecological status) for this type of river. Often, these exceedances were missed by the limited regulatory monitoring procedures undertaken by the Environment Agency. There is evidence that these spikes of elevated concentrations of P may have a biological impact on benthic invertebrate (e.g. blue-winged olive mayfly) communities that exist in these ecologically sensitive chalk streams. Further research is required to assess the ecological impact of P and how this might have implications for the development of future environmental regulations.

Activated carbon biochar from municipal waste as a sorptive agent for the removal of polyaromatic hydrocarbons (PAHs), phenols and petroleum based compounds in contaminated liquids

Wastewater (WW) sludge cake is problematic to dispose of with treatment unable to remove organic pollutants. Typical disposal options include landfill or deposition on agricultural land, at considerable expense and environmental impact. Pyrolysis can recycle this waste to biochar however, additional unwanted organic pollutants are generated, differing in composition and volume according to the feedstock. These pollutants can be captured in solvent impingers or 'scrubbers' to avoid environmental release but lead to alternative waste. Both activated carbon and biochar are proven clean-up methods for organic pollutants with pine wood biochar showing changes in extraction selectivity with preparation temperature. Activated carbon biochar (ACB) from pine wood has also been successfully compared as a substitute at reduced cost and improved efficacy. To our knowledge, ACB from sludge cake has remained untested along with its application to clean-up solvent scrubbers. We have investigated this material from two WW treatment plants (UK and Ghana) as a sorbent, generated at 400 and 700 °C, to minimise contamination of liquids from pyrolysis and, petrochemicals in the event of a spill. This study confirmed the use and selective production of ACB for preferential clean-up of specific pollutants. Despite high temperature pine wood ACB proving most effective in removing petrochemical mixtures (>76%) extractions of equivalent repeatability and reasonable recovery were achieved with low temperature sludge cake ACB. This re-use of waste sludge cake offers improved thermochemical (recycling) and WW process efficiency, limiting the environmental impact and overall operational costs, minimising waste for disposal.

Replication of Crohn's Disease Mucosal E. coli Isolates inside Macrophages Correlates with Resistance to Superoxide and Is Dependent on Macrophage NF-kappa B Activation

Mucosa-associated Escherichia coli are increased in Crohn’s disease (CD) and colorectal cancer (CRC). CD isolates replicate within macrophages but the specificity of this effect for CD and its mechanism are unclear. Gentamicin exclusion assay was used to assess E. coli replication within J774.A1 murine macrophages. E. coli growth was assessed following acid, low-nutrient, nitrosative, oxidative and superoxide stress, mimicking the phagolysosome. Twelve of 16 CD E. coli isolates replicated >2-fold within J774.A1 macrophages; likewise for isolates from 6/7 urinary tract infection (UTI), 8/9 from healthy subjects, compared with 2/6 ulcerative colitis, 2/7 colorectal cancer and 0/3 laboratory strains. CD mucosal E. coli were tolerant of acidic, low-nutrient, nitrosative and oxidative stress. Replication within macrophages correlated strongly with tolerance to superoxide stress (rho = 0.44, p = 0.0009). Exemplar CD E. coli HM605 and LF82 were unable to survive within Nfκb1^-/- murine bone marrow-derived macrophages. In keeping with this, pre-incubation of macrophages with hydrocortisone (0.6 µM for 24 h) caused 70.49 ± 12.11% inhibition of intra-macrophage replication. Thus, CD mucosal E. coli commonly replicate inside macrophages, but so do some UTI and healthy subject strains. Replication correlates with resistance to superoxide and is highly dependent on macrophage NF-κB signalling. This may therefore be a good therapeutic target.

European postgraduate curriculum in geriatric medicine developed using an international modified Delphi technique

BACKGROUND

the European Union of Medical Specialists (UEMS-GMS) recommendations for training in Geriatric Medicine were published in 1993. The practice of Geriatric Medicine has developed considerably since then and it has therefore become necessary to update these recommendations.

METHODS

under the auspices of the UEMS-GMS, the European Geriatric Medicine Society (EuGMS) and the European Academy of Medicine of Ageing (EAMA), a group of experts, representing all member states of the respective bodies developed a new framework for education and training of specialists in Geriatric Medicine using a modified Delphi technique. Thirty-two expert panel members from 30 different countries participated in the process comprising three Delphi rounds for consensus. The process was led by five facilitators.

RESULTS

the final recommendations include four different domains: 'General Considerations' on the structure and aim of the syllabus as well as quality indicators for training (6 sub-items), 'Knowledge in patient care' (36 sub-items), 'Additional Skills and Attitude required for a Geriatrician' (9 sub-items) and a domain on 'Assessment of postgraduate education: which items are important for the transnational comparison process' (1 item).

CONCLUSION

the current publication describes the development of the new recommendations endorsed by UEMS-GMS, EuGMS and EAMA as minimum training requirements to become a geriatrician at specialist level in EU member states.

Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey

In 2011, the Fourth National Audit Project (NAP4) reported high rates of airway complications in adult intensive care units (ICUs), including death or brain injury, and recommended preparation for airway difficulty, immediately available difficult airway equipment and routine use of waveform capnography monitoring. More than 80% of UK adult intensive care units have subsequently changed practice. Undetected oesophageal intubation has recently been listed as a 'Never Event' in UK practice, with capnography mandated. We investigated whether the NAP4 recommendations have been embedded into paediatric and neonatal intensive care practice by conducting a telephone survey of senior medical or nursing staff in UK paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). Response rates were 100% for paediatric intensive care units and 90% for neonatal intensive care units. A difficult airway policy existed in 67% of paediatric intensive care units and in 40% of neonatal intensive care units; a pre-intubation checklist was used in 70% of paediatric intensive care units and in 42% of neonatal intensive care units; a difficult intubation trolley was present in 96% of paediatric intensive care units and in 50% of neonatal intensive care units; a videolaryngoscope was available in 55% of paediatric intensive care units and in 29% of neonatal intensive care units; capnography was 'available' in 100% of paediatric intensive care units and in 46% of neonatal intensive care units, and 'always available' in 100% of paediatric intensive care units and in 18% of neonatal intensive care units. Death or serious harm occurring secondary to complications of airway management in the last 5 years was reported in 19% of paediatric intensive care units and in 26% of neonatal intensive care units. We conclude that major gaps in optimal airway management provision exist in UK paediatric intensive care units and especially in UK neonatal intensive care units. Wider implementation of waveform capnography is necessary to ensure compliance with the new 'Never Event' and has the potential to improve airway management.

Comprehensive vaccine design for commensal disease progression

Commensal organisms with the potential to cause disease pose a challenge in developing treatment options. Using the example featured in this study, pneumococcal disease begins with Streptococcus pneumoniae colonization, followed by triggering events that prompt the release of a virulent subpopulation of bacteria. Current vaccines focus on colonization prevention, which poses unintended consequences of serotype niche replacement. In this study, noncovalent colocalization of two classes of complementary antigens, one to prevent the colonization of the most aggressive S. pneumoniae serotypes and another to restrict virulence transition, provides complete vaccine effectiveness in animal subjects and the most comprehensive coverage of disease reported to date. As a result, the proposed vaccine formulation offers universal pneumococcal disease prevention with the prospect of effectively managing a disease that afflicts tens to hundreds of millions globally. The approach more generally puts forth a balanced prophylactic treatment strategy in response to complex commensal-host dynamics.

Risk factors in equine transport-related health problems: A survey of the Australian equine industry

BACKGROUND

Transportation can affect equine health and is a potential source of economic loss to the industry.

OBJECTIVES

To identify journey (duration, vehicle, commercial or noncommercial) and horse (sex, age, breed, use, amateur or professional status) characteristics associated with the development of transport-related health problems in horses.

STUDY DESIGN

Cross-sectional online survey.

METHODS

An online survey was conducted targeting amateur and professional participants in the Australian equine industry; eligible respondents were required to organise horse movements at least monthly. Respondents provided details of the last case of a transport-related health problem that had affected their horse(s). Associations between type of health problem, journey and horse characteristics were examined with multivariable multinomial regression analysis.

RESULTS

Based on 214 responses, health problems were classified as injuries, muscular problems, heat stroke, gastrointestinal and respiratory problems, and death or euthanasia. Respiratory problems were reported most frequently (33.7%), followed by gastrointestinal problems (23.8%) and traumatic injuries (16.3%). The type of health problem was associated with journey duration (P<0.001) and horse breed (P = 0.001). Injuries were more likely to occur on short journeys, whereas more severe illnesses (gastrointestinal and respiratory problems, and death or euthanasia) were more likely to occur on long journeys. Using Standardbreds as the reference group, Thoroughbreds, Arabians and Warmbloods were more likely to experience a severe illness than an injury.

MAIN LIMITATIONS

Self-selected participation in the study and the self-reported nature of transport-related problems.

CONCLUSIONS

Horses undertaking journeys of longer than 24 h are at greater risk for the development of severe disease or death. Further studies on long-haul transportation effects are required to safeguard the welfare of horses moved over long distances.

In situ pneumococcal vaccine production and delivery through a hybrid biological-biomaterial vector

The type and potency of an immune response provoked during vaccination will determine ultimate success in disease prevention. The basis for this response will be the design and implementation of antigen presentation to the immune system. Whereas direct antigen administration will elicit some form of immunological response, a more sophisticated approach would couple the antigen of interest to a vector capable of broad delivery formats and designed for heightened response. New antigens associated with pneumococcal disease virulence were used to test the delivery and adjuvant capabilities of a hybrid biological-biomaterial vector consisting of a bacterial core electrostatically coated with a cationic polymer. The hybrid design provides (i) passive and active targeting of antigen-presenting cells, (ii) natural and multicomponent adjuvant properties, (iii) dual intracellular delivery mechanisms, and (iv) a simple formulation mechanism. In addition, the hybrid format enables device-specific, or in situ, antigen production and consolidation via localization within the bacterial component of the vector. This capability eliminates the need for dedicated antigen production and purification before vaccination efforts while leveraging the aforementioned features of the overall delivery device. We present the first disease-specific utilization of the vector toward pneumococcal disease highlighted by improved immune responses and protective capabilities when tested against traditional vaccine formulations and a range of clinically relevant Streptococcus pneumoniae strains. More broadly, the results point to similar levels of success with other diseases that would benefit from the production, delivery, and efficacy capabilities offered by the hybrid vector.

Colonic mucosa-associated diffusely adherent afaC+ Escherichia coli expressing lpfA and pks are increased in inflammatory bowel disease and colon cancer

OBJECTIVE

Colonic mucosa-associated Escherichia coli are increased in Crohn's disease (CD) and colorectal cancer (CRC). They variously haemagglutinate, invade epithelial cell lines, replicate within macrophages, translocate across M (microfold) cells and damage DNA. We investigated genes responsible for these effects and their co-association in colonic mucosal isolates.

DESIGN

A fosmid library yielding 968 clones was prepared in E coli EPI300-T1 using DNA from a haemagglutinating CRC isolate, and resulting haemagglutinating clones were 454-pyrosequenced. PCR screening was performed on 281 colonic E coli isolates from inflammatory bowel disease (IBD) (35 patients), CRC (21) and controls (24; sporadic polyps or irritable bowel syndrome).

RESULTS

454-Pyrosequencing of fosmids from the haemagglutinating clones (n=8) identified the afimbrial adhesin afa-1 operon. Transfection of afa-1 into E coli K-12 predictably conferred diffuse adherence plus invasion of HEp-2 and I-407 epithelial cells, and upregulation of vascular endothelial growth factor. E coli expressing afaC were common in CRC (14/21, p=0.0009) and CD (9/14, p=0.005) but not ulcerative colitis (UC; 8/21) compared with controls (4/24). E coli expressing both afaC and lpfA (relevant to M-cell translocation) were common in CD (8/14, p=0.0019) and CRC (14/21, p=0.0001), but not UC (6/21) compared with controls (2/24). E coli expressing both afaC and pks (genotoxic) were common in CRC (11/21, p=0.0015) and UC (8/21, p=0.022), but not CD (4/14) compared with controls (2/24). All isolates expressed dsbA and htrA relevant to intra-macrophage replication, and 242/281 expressed fimH encoding type-1 fimbrial adhesin.

CONCLUSIONS

IBD and CRC commonly have colonic mucosal E coli that express genes that confer properties relevant to pathogenesis including M-cell translocation, angiogenesis and genotoxicity.

Soluble plantain fibre blocks adhesion and M-cell translocation of intestinal pathogens

Dietary fibres may have prebiotic effects mediated by promotion of beneficial bacteria. This study explores the possibility that soluble plant fibre may also improve health by inhibiting epithelial adhesion and translocation by pathogenic bacteria. We have focussed on soluble non-starch polysaccharide (NSP) from plantain bananas (Musa spp.) which previous studies showed to be particularly effective at blocking Escherichia coli epithelial adherence. In vitro and ex vivo studies assessed the ability of plantain NSP to inhibit epithelial cell adhesion and invasion of various bacterial pathogens, and to inhibit their translocation through microfold (M)-cells and human Peyer′s patches mounted in Ussing chambers. Plantain NSP showed dose-related inhibition of epithelial adhesion and M-cell translocation by a range of pathogens. At 5 mg/ml, a concentration readily achievable in the gut lumen, plantain NSP inhibited adhesion to Caco2 cells by Salmonella Typhimurium (85.0±8.2%, P<.01), Shigella sonnei (46.6±29.3%, P<.01), enterotoxigenic E.coli (56.1±23.7%, P<.05) and Clostridium difficile (67.6±12.3%, P<.001), but did not inhibit adhesion by enteropathogenic E.coli. Plantain NSP also inhibited invasion of Caco2 cells by S. Typhimurium (80.2 ± 9.7%) and Sh. sonnei (46.7±13.4%); P<.01. Plantain NSP, 5 mg/ml, also inhibited translocation of S. Typhimurium and Sh. sonnei across M-cells by 73.3±5.2% and 46.4±7.7% respectively (P<.05). Similarly, S. Typhimurium translocation across Peyer′s patches was reduced 65.9±8.1% by plantain NSP (P<.01). Soluble plantain fibre can block epithelial adhesion and M-cell translocation of intestinal pathogens. This represents an important novel mechanism by which soluble dietary fibres can promote intestinal health and prevent infective diarrhoea.

The prevalence of health care-associated infection in older people in acute care hospitals

OBJECTIVE

To determine the prevalence of health care-associated infection (HAI) in older people in acute care hospitals, detailing the specific types of HAI and specialties in which these are most prevalent.

DESIGN

Secondary analysis of the Scottish National Healthcare Associated Infection Prevalence Survey data set.

PATIENTS AND SETTING

All inpatients in acute care (n = 11,090) in all acute care hospitals in Scotland (n = 45).

RESULTS

The study found a linear relationship between prevalence of HAI and increasing age (P<.0001) in hospital inpatients in Scotland. Urinary tract infections and gastrointestinal infections represented the largest burden of HAI in the 75-84- and over-85-year age groups, and surgical-site infections represented the largest burden in inpatients under 75 years of age. The prevalence of urinary catheterization was higher in each of the over-65 age groups (P<.0001). Importantly, this study reveals that a high prevalence of HAI in inpatients over the age of 65 years is found across a range of specialties within acute hospital care. An increased prevalence of HAI was observed in medical, orthopedic, and surgical specialties.

CONCLUSIONS

HAI is an important outcome indicator of acute inpatient hospital care, and our analysis demonstrates that HAI prevalence increases linearly with increasing age (P<.0001). Focusing interventions on preventing urinary tract infection and gastrointestinal infections would have the biggest public health benefit. To ensure patient safety, the importance of age as a risk factor for HAI cannot be overemphasized to those working in all areas of acute care.

Preclinic group education sessions reduce waiting times and costs at public pain medicine units

OBJECTIVE

To assess the effects of preclinic group education sessions and system redesign on tertiary pain medicine units and patient outcomes.

DESIGN

Prospective cohort study.

SETTING

Two public hospital multidisciplinary pain medicine units.

PATIENTS

People with persistent pain.

INTERVENTIONS

A system redesign from a "traditional" model (initial individual medical appointments) to a model that delivers group education sessions prior to individual appointments. Based on Patient Triage Questionnaires patients were scheduled to attend Self-Training Educative Pain Sessions (STEPS), a two day eight hour group education program, followed by optional patient-initiated clinic appointments.

OUTCOME MEASURES

Number of patients completing STEPS who subsequently requested individual outpatient clinic appointment(s); wait-times; unit cost per new patient referred; recurrent health care utilization; patient satisfaction; Global Perceived Impression of Change (GPIC); and utilized pain management strategies.

RESULTS

Following STEPS 48% of attendees requested individual outpatient appointments. Wait times reduced from 105.6 to 16.1 weeks at one pain unit and 37.3 to 15.2 weeks at the second. Unit cost per new patient appointed reduced from $1,805 Australian Dollars (AUD) to AUD$541 (for STEPS). At 3 months, patients scored their satisfaction with "the treatment received for their pain" more positively than at baseline (change score=0.88; P=0.0003), GPIC improved (change score=0.46; P<0.0001) and mean number of active strategies utilized increased by 4.12 per patient (P=0.0004).

CONCLUSIONS

The introduction of STEPS was associated with reduced wait-times and costs at public pain medicine units and increased both the use of active pain management strategies and patient satisfaction.

The UK proposals for revalidation of physicians: Implications for the recertification of surgeons

The editorial titled "For the Protection of the Public and the Good of the Specialty: Maintenance of Certification" (published in the February 2009 issue of the Archives of Surgery) has prompted us to offer the following article to inform the debate about how assessing surgical care and sorting out the variables to be included in maintenance of certification may develop worldwide. The proposals for revalidation of UK physicians involve the relicensing of all physicians and recertification of all specialists on the specialist register of the General Medical Council. The process will be on a 5-year cycle and is currently under development by the General Medical Council. The Royal Colleges have been charged with creating the standards for recertification, and the responsibility will fall on the Royal Colleges to support their fellows and members as the new regulation is introduced and as it develops. This article outlines developments so far, with particular reference to surgeons.

The Evaluation of Formulations for the Preparation of Pellets with High Drug Loading by Extrusion/Spheronization

A capillary rheometer was used to evaluate rheological properties and the fluid mobility of mixtures with a high drug loading (80%) of three model drugs (ibuprofen, lactose, and ascorbic acid) when extruded. These drugs have a range of solubility in water, with 20% microcrystalline cellulose (MCC) as the spheronization aid, and water, pH 2.0, and pH 10.0 buffer as the binder liquid. The results were compared with the ability of the systems to form spherical pellets by the process of extrusion/spheronization. It was found possible to produce round pellets with a narrow size distribution by the process of extrusion/spheronization for formulations containing 80% of either lactose or ascorbic acid with MCC as the spheronization aid. It was not, however, possible to form pellets containing the same level of ibuprofen. This appears to be associated with the high level of fluid mobility observed when the wet masses were extruded in a ram extruder. A range of rheological characteristics in terms of shear stress, die entry pressure, angles of convergence, extensional flow, and elasticity were determined, but the variations in the values of these, which were observed, did not give an indication of the ability of the wet mass to form spherical pellets when subjected to the spheronization process. This could be associated with the fact that the selection of the conditions necessary to provide a valid quantification of the extrusion process did not truly represent the stability of the systems in terms of the mobility of the fluid when the wet mass was processed. The formulation of a wet mass with limited fluid mobility appears to be the first priority of formulations used in extrusion/spheronization.

Host-bacteria interaction in inflammatory bowel disease

INTRODUCTION/BACKGROUND

Inflammatory bowel disease (IBD) results from complex interactions between: host genome, immune system, mucosa, bacteria, and environment.

SOURCES OF DATA

Review of PubMed database using search terms 'bacteria and inflammatory bowel disease' and 'genetics and inflammatory bowel disease'. PubMed 'related reference' feature and references from retrieved articles were examined.

AREAS OF AGREEMENT

IBD results from interaction between the microbiota of the gut and the immune system. Key gene defects associated with IBD are involved in bacterial recognition and processing. The environment at least modifies and may determine pathogenesis.

AREAS OF CONTROVERSY

It has been disputed whether the primary defect in IBD is immunological or bacterial, and which bacteria are key. GROWING POINTS/AREAS FOR RESEARCH: 'M cells', the specialized epithelial cells that overlie Peyer's patches, are a major interface between gut bacteria and the immune system. Improved understanding is needed of the bacteria involved in IBD pathogenesis, their genotypes and phenotypes, their portal of entry and their mechanism for escaping attack from the immune system. Bacterial ligands involved in bacteria-epithelial adhesion are emerging, and molecular techniques are rapidly increasing our knowledge of the human intestinal microbiota.

cDNA cloning and substrate specificity of equine tryptase, a possible mediator in equine heaves

BACKGROUND

Mast cell mediators are believed to play a central role in inflammatory lung disorders such as human allergic and occupational asthma. Equine heaves is characterized by reversible neutrophilic airway inflammation and airway obstruction, primarily due to bronchospasm and mucus hypersecretion, following exposure of susceptible horses to organic stable dusts. As such, heaves shares many similarities with human occupational dust-induced asthma and therefore it is proposed that mast cells may also be implicated in the pathogenesis of heaves. Tryptase, a mast cell-specific proteinase, can be used as an indicator of biological mast cell activity.

OBJECTIVE

The aim of this study was to determine the cDNA sequence of equine tryptase and to investigate its substrate specificity in order to rationalize its enzymatic activity.

METHODS

RT-PCR cloning was used to sequence equine tryptase. Substrate specificity of equine tryptase was investigated using arginine and lysine containing substrates.

RESULTS

The cDNA and deduced amino acid (Aa) sequences for equine tryptase shared strong identity with other tryptases. Unusually for a trypsin-like proteinase however, equine tryptase has alanine at residue 216, rather than glycine, which confers increased arginine substrate specificity in vitro and may restrict fibrinogenolysis in vivo.

CONCLUSION

Cloning and sequencing of the mast cell proteinase equine tryptase will allow molecular probing of its expression in the lung of control and heaves-affected horses. Further work is warranted to determine the biological relevance of the unique alanine 216 substitution in the molecular sequence of the equine tryptase substrate-binding pocket.

Omenn syndrome: therapeutic effects of cyclosporin

Omenn syndrome is a severe combined immunodeficiency with features of generalised erythroderma alopecia and evidence of Th2 inflammation (eosinophilia and raised IgE). We describe a differential effect of 2 calcineurin inhibitors, cyclosporine A (CsA) and tacrolimus, with CsA rapidly improving the erythroderma and lymphocytosis but tacrolimus having little effect.

Alterations in grip strength during male sexual arousal

Although it is known that alterations in grip strength occur under a number of conditions, little is known about relationships between grip strength and sexual arousal. This relationship was investigated in 30 healthy heterosexual males, who viewed both erotic and nonerotic videos. A questionnaire was used to assess the extent of sexual arousal. The grip strengths of both hands were measured with a five-position (P1-P5) dynamometer, before and after watching the videos. After watching the erotic video, there was a statistically significant reduction in grip strength for the P2 position, with nonsignificant overall reductions in grip strength for all other positions tested. No such effect was observed in control tests. The results indicate that during sexual arousal, the neural system is likely to reduce the output to muscles not directly related to sexual function, presumably to enhance the physiological responses of sexual arousal.