An ecological and epidemiological single-season survey of Anaplasma and Ehrlichia positive ticks in Victoria Falls National Park, Zimbabwe

There is an urgent need for continued research on the ecology of tick-borne diseases in Africa. Our objective was to provide a preliminary description of the ecology and epidemiology of tick species, tick-borne pathogens, and animal hosts in Zimbabwe, focusing efforts at Victoria Falls National Park, for a single season. We tested the hypothesis that tick surveillance and pathogen screening data can be used to model associations among ticks, hosts, and pathogens. We collected ticks from domesticated animals and wildlife in Zimbabwe and screened the ticks for the presence of Anaplasma and Ehrlichia bacteria. Nearly 30% of the screened ticks were PCR-positive; 89% of tick species were PCR-positive, and 88% of animal species carried at least one PCR-positive tick. We sequenced a subset of amplicons that were similar to three Anaplasma species and three Ehrlichia species. The odds of a tick being PCR-positive increased when many ticks were collected from the host or the tick was collected from a cow (domesticated animal). Tick species shared host species more often than expected. We demonstrate that ticks in northwestern Zimbabwe present a One Health problem for nearby wildlife and humans.

Maternal heart rate variability patterns associated with maternal hypotension and non-reassuring fetal heart rate patterns following initiation of combined spinal-epidural labor analgesia: a prospective observational trial

BACKGROUND

We evaluated whether baseline maternal heart rate variability (HRV), including the Analgesia Nociception Index (ANI), is associated with maternal hypotension and fetal heart rate (FHR) abnormalities following combined spinal-epidural (CSE) labor analgesia.

METHODS

Laboring women were enrolled in this prospective observational study. The primary endpoint was maternal hypotension. The secondary endpoint was FHR abnormalities within 30 min following CSE analgesia initiated with intrathecal plain bupivacaine 1.0 mg and fentanyl 20 µg. The maternal ANI, electrocardiogram, blood pressure, heart rate, oxygen saturation, and FHR tracings were recorded 15 min before and 30 min after CSE. Parturients were grouped based on presence of hypotension and FHR abnormalities. Patient demographics and HRV metrics were compared. Receiver operating characteristics (ROC) curves were constructed for the prediction of hypotension and FHR abnormalities.

RESULTS

No significant intergroup differences were detected in patient characteristics. Several baseline HRV metrics and ANI differed significantly between the normotensive (n = 50) and hypotensive (n = 31) groups and between parturients showing FHR abnormalities (n = 19) and those showing reassuring FHR traces (n = 62). The area under the ROC curve (AUC) for predicting hypotension of the baseline low-frequency (LF)/high-frequency (HF) ratio was 0.677 (95% CI 0.55 to 0.80), and that of the ANI was 0.858 (95% CI 0.78 to 0.94). For predicting non-reassuring FHR patterns, the AUC of the LF/HF ratio was 0.77 (95% CI 0.65 to 0.89), and that of the ANI was 0.833 (95% CI 0.72 to 0.94).

CONCLUSIONS

The ANI can predict the propensity for maternal hypotension and non-reassuring FHR patterns following CSE.

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.

POS0926 HOW GOOD ARE WE AT CAPTURING THE GI SYMPTOMS IN OUR PATIENTS WITH SCLERODERMA?

Background

Scleroderma is a rare autoimmune condition affecting around 1 in 10,000 individuals causing multisystem inflammation and fibrosis. The gastrointestinal (GI) system is the most commonly affected system, with nearly 90% of patients experiencing GI manifestations. The disease can affect any part of the GI tract with symptoms ranging in severity. Complications include oesophagitis and oesophageal strictures, vascular lesions in the stomach, reduced movement and absorption within the intestines and anorectal involvement. Recent guidance by the BSR highlight the importance of GI complications.

Objectives

To conduct a quality improvement project to improve the care provided to our scleroderma patients, focusing on GI symptom burden and identifying any unmet need when comparing local care to BSR guidelines and consensus best practice guidelines.

Methods

A proforma was developed for assessing and treating GI symptoms based on BSR and consensus best practice guidelines. This proforma was trialled on an initial cohort of 32 scleroderma patients from the Royal Glamorgan Hospital in Wales. The last clinical assessment was assessed for the following - regurgitation, nausea, vomiting, heartburn, dysphagia, abdominal pain, bloating, diarrhoea, faecal incontinence, constipation and weight loss. The symptoms were recorded as present, not present or not documented. The management of symptoms were evaluated against the guidelines. The cohort were then contacted regarding their last clinical assessment and asked if they were experiencing these symptoms at the time of their last assessment. The results from the documented assessment were compared to the additional patient information to address unmet needs.

Results

The results show that there is limited documentation of the presence of GI symptoms amongst scleroderma patients at clinic appointments. The initial assessment results were compared with the subsequent patient telephone reported symptoms in order to identify unmet need. The following refer to unidentified symptoms at assessment - regurgitation 9%, nausea 6%, vomiting 3%, heartburn 31%, dysphagia 31%, abdominal pain 9%, bloating 25%, diarrhoea 6%, faecal incontinence 9%, constipation 15% and weight loss 19%. Many patients stated they were unaware that their condition could cause GI symptoms and would not routinely mention these symptoms in a rheumatology assessment.

The proforma proves to be an effective way to document and guide management of these patients. The clinical proforma that has now been created will help us improve patient care which can be reassessed in the future.

Table 1.SymptomsManagementRegurgitation1 case - not investigated due to pre-existing dysmotilityNausea0 casesVomiting0 casesHeartburn4 cases – 3 on PPIs, 1 gastroscopy arrangedDysphagia6 cases – 2 of known dysmotility, 3 not investigatedAbdominal pain2 cases – not investigatedBloating1 case – not investigatedDiarrhoea0 casesFaecal incontinence1 case – MRI arranged for query small bowel obstructionConstipation4 cases – 1 longstanding issue, 1 MRI arranged, 2 not investigatedWeight loss1 case – not investigated

Conclusion

The piloting of our proforma of the GI assessment of patients with scleroderma has identified that the documentation of GI symptoms was poor. We don’t know whether GI symptomology was discussed during assessment however it’s evident that it was not often documented. Patients don’t always report symptoms unless targeted questions are asked. A clinic proforma would be invaluable, leading to an increased awareness amongst both practitioners and patients of the potential clinical manifestations. Having presented this data locally we have now introduced such a proforma and will re-evaluate clinical practice in the future. Sharing this information will hopefully help improve patient care elsewhere.

References

[1]Hansi N, Thoua N, Carulli M, Chakravarty K, Lal S, Smyth A, et al. Consensus best practice pathway of the UK scleroderma study group: gastrointestinal manifestations of systemic sclerosis. Clin Exp Rheumatol. 2014; 32(6 Suppl 86):S-214-21.

Disclosure of Interests

None declared

Development, validity and reliability testing of the East Midlands Evaluation Tool (EMET) for measuring impacts on trainees' confidence and competence following end of life care training

OBJECTIVES

To develop, test and validate a versatile questionnaire, the East Midlands Evaluation Tool (EMET), for measuring effects of end of life care training events on trainees' self-reported confidence and competence.

METHODS

A paper-based questionnaire was designed on the basis of the English Department of Health's core competences for end of life care, with sections for completion pretraining, immediately post-training and also for longer term follow-up. Preliminary versions were field tested at 55 training events delivered by 13 organisations to 1793 trainees working in diverse health and social care backgrounds. Iterative rounds of development aimed to maximise relevance to events and trainees. Internal consistency was assessed by calculating interitem correlations on questionnaire responses during field testing. Content validity was assessed via qualitative content analysis of (1) responses to questionnaires completed by field tester trainers and (2) field notes from a workshop with a separate cohort of experienced trainers. Test-retest reliability was assessed via repeat administration to a cohort of student nurses.

RESULTS

The EMET comprises 27 items with Likert-scaled responses supplemented with questions seeking free-text responses. It measures changes in self-assessed confidence and competence on 5 subscales: communication skills; assessment and care planning; symptom management; advance care planning; overarching values and knowledge. Test-retest reliability was found to be good, as was internal consistency: the questions successfully assess different aspects of the same underlying concept.

CONCLUSIONS

The EMET provides a time-efficient, reliable and flexible means of evaluating effects of training on self-reported confidence and competence in the key elements of end of life care.

The Role of Cognitive Factors in Predicting Balance and Fall Risk in a Neuro-Rehabilitation Setting

Introduction

There is a consistent body of evidence supporting the role of cognitive functions, particularly executive function, in the elderly and in neurological conditions which become more frequent with ageing. The aim of our study was to assess the role of different domains of cognitive functions to predict balance and fall risk in a sample of adults with various neurological conditions in a rehabilitation setting.

Methods

This was a prospective, cohort study conducted in a single centre in the UK. 114 participants consecutively admitted to a Neuro-Rehabilitation Unit were prospectively assessed for fall accidents. Baseline assessment included a measure of balance (Berg Balance Scale) and a battery of standard cognitive tests measuring executive function, speed of information processing, verbal and visual memory, visual perception and intellectual function. The outcomes of interest were the risk of becoming a faller, balance and fall rate.

Results

Two tests of executive function were significantly associated with fall risk, the Stroop Colour Word Test (IRR 1.01, 95% CI 1.00–1.03) and the number of errors on part B of the Trail Making Test (IRR 1.23, 95% CI 1.03–1.49). Composite scores of executive function, speed of information processing and visual memory domains resulted in 2 to 3 times increased likelihood of having better balance (OR 2.74 95% CI 1.08 to 6.94, OR 2.72 95% CI 1.16 to 6.36 and OR 2.44 95% CI 1.11 to 5.35 respectively).

Conclusions

Our results show that specific subcomponents of executive functions are able to predict fall risk, while a more global cognitive dysfunction is associated with poorer balance.

Development of an automatic quantification method for cancer tissue microarray study

Clinical Histopathology is based on the analysis of immunohistochemistry (IHC) stained tissue images. Selection of antibodies for detecting the presence, type, and grade of cancerous tissue has a great influence on the diagnostic potential of IHC tests. Automated evaluation methods for tissue microarrays applied to many combinations of antibody and tissue type can speed development of new clinical assays. We present an automatic method that successfully quantifies stain intensity, fraction of cells stained and sub-cellular location of staining in tissue microarray images. The method combines an opponent color preprocessor and a novel statistical approach for identifying brown and blue staining, followed by multilevel morphological processing. We verify the capability of our method by comparing the results to manually annotated image databases. We also demonstrate cross-tissue robustness using two clinical case study data.

Evaluation of executive functioning in people with intellectual disabilities

BACKGROUND

Executive functioning (EF) is an important concept in cognitive psychology that has rarely been studied in people with intellectual disabilities (IDs). The aim of this study was to examine the validity of two test batteries and the structure of EF in this client group.

METHODS

We administered the children's version of the Behavioural Assessment of the Dysexecutive Syndrome (BADS-C) and the Cambridge Executive Functioning Assessment (CEFA) for people with ID, to 40 participants who attended day centres for people with mild to moderate learning disabilities [mean full-scale intelligence quotient (IQ) = 59]. The BADS-C consists of six EF subtests while the CEFA contains eight EF (including two executive memory) subtests and four memory subtests. IQ and receptive language ability were also assessed. The results were subjected to principal components analysis, and regression analysis was used to examine the relationship of the ensuing factors to other cognitive variables.

RESULTS

Scores on both sets of EF tests were only weakly related to receptive language ability, and even more weakly related to IQ. Scores on the BADS-C were substantially lower than predicted from the published norms for people in higher IQ ranges, and many participants scored zero on three of the six subtests. This potential floor effect was less evident with scores on the CEFA. Principal components analyses produced one usable factor for the BADS-C, and two factors for the CEFA that differed in both the extent of involvement of working memory and the predominant sensory modality. A combined analysis of the subtests retained from both analyses produced three factors that related uniquely to aspects of IQ and memory.

CONCLUSIONS

The CEFA is suitable for use with people with mild to moderate learning disabilities, whereas the BADS-C is at the lower limit of usability with this client group. The lower-than-expected scores observed on the BADS-C may indicate that people known to learning disability services may be more impaired than people of comparable IQ not known to services. The structure of EF seen in people with IDs closely resembles a model of EF in the general population that has received a broad level of support.

Evaluation of the ability of people with intellectual disabilities to 'weigh up' information in two tests of financial reasoning

BACKGROUND

An assessment of mental capacity includes an evaluation of the ability to 'weigh up' information, but how to do this is uncertain. We have previously used a laboratory decision-making task, temporal discounting, which involves a trade-off between the value and the delay of expected rewards. Participants with intellectual disabilities (ID) showed very little evidence of 'weighing up' of information: only a third of participants showed consistent temporal discounting performance, and when present, consistent performance was usually impulsive; and the ability to perform consistently was more strongly related to executive functioning than to IQ. The aim of the present study was to replicate these observations and extend them to a more realistic financial decision-making task.

METHODS

We administered a temporal discounting task and a financial decision-making task, as well as tests of executive functioning and IQ, to 20 participants who attended day services for people with learning disabilities (mean Full-Scale IQ = 59), and to 10 staff members.

RESULTS

Performance in both decision-making tasks was related more strongly to executive functioning than to IQ. In both tasks, decisions by service users were made largely on the basis of a single item of information: there was very little evidence in either task that information from two sources was being 'weighed'.

CONCLUSIONS

The results suggest that difficulty in 'weighing up' information may be a general problem for people with ID, pointing to a need for psycho-educational remediation strategies to address this issue. The importance of executive functioning in decision-making by people with ID is not recognized in the legal test for mental capacity, which in practice includes a possibly irrelevant IQ criterion.

Deblurring molecular images using desorption electrospray ionization mass spectrometry

Traditional imaging techniques for studying the spatial distribution of biological molecules such as proteins, metabolites, and lipids, require the a priori selection of a handful of target molecules. Imaging mass spectrometry provides a means to analyze thousands of molecules at a time within a tissue sample, adding spatial detail to proteomic, metabolomic, and lipidomic studies. Compared to traditional microscopic images, mass spectrometric images have reduced spatial resolution and require a destructive acquisition process. In order to increase spatial detail, we propose a constrained acquisition path and signal degradation model enabling the use of a general image deblurring algorithm. Our analysis shows the potential of this approach and supports prior observations that the effect of the sprayer focuses on a central region much smaller than the extent of the spray.

Real-time PCR and its application to mumps rapid diagnosis

A real-time polymerase chain reaction assay was initially developed in China to detect mumps genome. The primers and TaqMan-MGB probe were selected from regions of the hemagglutinin gene of mumps virus. The primers and probe for the real-time PCR were evaluated by both laboratories in China and in the UK using three different pieces of equipment, LightCycler (Roche), MJ DNA Engine Option 2 (BIO-RAD) and TaqMan (ABI Prism) on different samples. The reaction was performed with either a one-step (China) or two-step (UK) process. The sensitivity (10 copies) was estimated using a serial dilution of constructed mumps-plasmid DNA and a linear standard curve was obtained between 10 and 10(7) DNA copies/reaction, which can be used to quantify viral loads. The detection limit on cell culture-grown virus was approximately 2 pfu/ml with a two-step assay on TaqMan, which was equivalent to the sensitivity of the nested PCR routinely used in the UK. The specificity was proved by testing a range of respiratory viruses and several genotypes of mumps strains. The concentration of primers and probe is 22 pmol and 6.25 or 7 pmol respectively for a 25 microl reaction. The assay took 3 hr from viral RNA extraction to complete the detection using any of the three pieces of equipment. Three hundred forty-one (35 in China and 306 in the UK) clinical specimens were tested, the results showing that this real-time PCR assay is suitable for rapid and accurate detection of mumps virus RNA in various types of clinical specimens.

High-speed plasmid isolation using 96-well, size-exclusion filter plates

The accelerating pace of genomics analysis has necessitated the abbreviation of DNA sample preparation protocols. We have developed a size-exclusion-based system for the rapid isolation ofplasmid DNA in a 96-well microplate format. This high-speed protocol employs a modified alkaline lysis methodfor the preparation of the bacterial lysate, followed by three short vacuum filtration steps. Unlike traditional bind/wash/elute methods, there is no need to use chaotropic salts or ethanol. The samples are recovered from the top side of the MultiScreen96 PLASMID plates. Starting with bacterial cell pellets, the entire prycedure for purifying the plasmid DNA can be performed in 30 min with a multichannel pipettor. The high yields, reproducibility, and quality of the plasmids make this system a good choice for any cloning or DNA sequencing operation.

Expression of neuropilin-1 by human glomerular epithelial cells in vitro and in vivo

Vascular endothelial growth factor (VEGF) is a potent promoter of endothelial mitogenesis and of endothelial permeability. Within the kidney it is synthesized primarily in the visceral glomerular epithelial cells (vGECs); however, the role of VEGF in the glomerulus remains unknown, as does the target cell upon which it acts. Although the target cells may be those of the glomerular endothelium, there are micro-anatomical reasons why this might not be the case. This, therefore, led us to consider the possibility that glomerular VEGF may bind to the vGECs themselves. Since it has been shown that vGECs do not express the main tyrosine kinase VEGF receptors, we chose to study vGEC expression of the more recently described VEGF isoform-specific receptors, the neuropilins. The expression of mRNAs for neuropilin-1, neuropilin-2 and soluble neuropilin was studied in whole kidney, sieved glomeruli and cultured podocytes by reverse transcription-PCR, and neuropilin-1 mRNA expression in isolated single glomeruli was analysed by nested reverse transcription-PCR. The expression of neuropilin-1 protein was investigated in cultured vGECs by Western blotting and immunocytochemistry, and in normal kidney sections by immunohistochemistry. Neuropilin-1 mRNA was detected in whole kidney, single and sieved glomeruli and cultured vGECs. Neuropilin-1 protein was detected in cultured vGECs and in vGECs in normal kidney sections by immunohistochemistry. Thus the present study suggests that vGECs may have the potential to bind the VEGF that they secrete. Functional studies will be required to address the potential significance of this finding in terms of an autocrine loop or VEGF sequestration.

Compression of femoral vein by the strap of a urine-collecting device in a spinal cord injury patient

OBJECTIVE

To report an unusual cause of femoral vein compression in a spinal cord injury (SCI) patient.

DESIGN

A case report of a SCI patient in whom the strap of a urinal produced compression of femoral vein. Setting Regional Spinal Injuries Centre, Southport, England.

SUBJECT

A 65-year old male, who had sustained paraplegia at T-10 level 33 years ago, attended the spinal unit for a routine follow-up intravenous urography (IVU). He was wearing a urinal, which was held tightly over the penis by means of two straps coursing over the inguinal regions.

MAIN OUTCOME MEASURES

IVU was performed by injecting 50 ml of Ultravist-300 via a 23-gauge butterfly needle inserted in a vein over the dorsum of the left foot. After completion of the injection, an X-ray of the pelvis was taken to evaluate the right hip. This showed contrast in the vena profunda femoris, circumflex femoral veins and inter-muscular veins with evidence of compression of proximal femoral vein.

RESULTS

It was suspected that the strap holding the urinal was causing compression of the femoral vein. Therefore, a venogram was performed 5 days later, when the patient had discarded the urinal and the straps. This showed free flow of contrast through the left femoral and iliac veins.

CONCLUSION

Compression of femoral vein by a strap holding the urinal was discovered serendipitously in this patient during a routine follow-up. Physicians and health professionals should bear in mind this rare complication when examining spinal cord injury patients who use this type of urine collecting device, and discuss with them alternative methods for urinary drainage.

A second-generation genomewide screen for asthma-susceptibility alleles in a founder population

A genomewide screen for asthma- and atopy-susceptibility loci was conducted, using 563 markers, in 693 Hutterites who are members of a single 15-generation pedigree, nearly doubling the sample size from the authors' earlier studies. The resulting increase in power led to the identification of 23 loci in 18 chromosomal regions showing evidence for linkage that is, in general, 10-fold more significant (P<.001 vs. P<.01) than the linkages reported previously in this population. Moreover, linkages to loci in 11 chromosomal regions were identified for the first time in the Hutterites in this report, including five regions (5p, 5q, 8p, 14q, and 16q) showing evidence both of linkage, by the likelihood ratio (LR) chi(2), and of disequilibrium, by the transmission/disequilibrium test. A region on chromosome 19 continues to show evidence for linkage, by both tests, in this study. Studies of 17 candidate genes provide evidence for association with variation in the IL4RA gene (16p12), the HLA class II genes (6p21), and the interferon-alpha gene cluster (9p22), but the lack of evidence for linkage in these regions by the LR chi(2) test suggests that these are minor susceptibility loci. A polymorphism in the CD14 gene is in linkage disequilibrium with an as yet unidentified susceptibility allele in the 5q cytokine cluster, a region showing evidence for linkage among the Hutterites. Finally, 10 of the regions showing evidence for linkage in the Hutterites have shown evidence of linkage to related phenotypes in other genome screens, suggesting that these regions may contain common alleles that have relatively large effects on asthma and atopy phenotypes in diverse populations.

beta(2)-adrenergic receptor Arg16/Arg16 genotype is associated with reduced lung function, but not with asthma, in the Hutterites

In a genome-wide screen for asthma loci in the Hutterites, a marker locus on chromosome 5q23-31 showed evidence of linkage to asthma (C. Ober and colleagues, Hum. Molec. Genet. 1998;7:1393). To determine whether the beta(2)-adrenergic receptor (beta(2)AR) gene is the 5q-linked asthma locus in the Hutterites, we genotyped this sample for polymorphisms in the beta(2)AR gene. Neither the Arg16Gly nor Gln27Glu polymorphisms showed evidence of linkage to qualitative measures of asthma and bronchial hyperresponsiveness (BHR) (p > 0.10) or to quantitative measures of serum IgE and airway reactivity (p > 0.10). In contrast, FEV(1) percentage of predicted and FVC percentage of predicted were significantly lower among individuals homozygous for the Arg16 allele (FEV(1) %: 98.3 +/- 13.2% versus 103. 8 +/- 14.9%, p = 0.003; FVC %: 104.2 +/- 12.3% versus 108.3 +/- 13. 2%, p = 0.02 by t test). These findings held true for adolescents and adults, but not for children </= 12 yr of age. This study demonstrates that the observed linkage to asthma in the 5q23-31 region is unrelated to variation in the beta(2)AR gene. However, it is the first study to suggest that the beta(2)AR Arg16Gly polymorphism influences either lung growth or the rate of decline of lung function with age.

HLA-DRB1*01 alleles are associated with sensitization to cockroach allergens

BACKGROUND

Sensitization to cockroach allergens is an important epidemiologic risk factor for asthma, particularly among African Americans living in urban environments. A recent genome screen in the Hutterites, a white founder population, identified a linkage between an HLA-linked marker and sensitization to cockroach allergens.

OBJECTIVE

Our purpose was to determine whether alleles at one or more HLA loci are associated with sensitization to cockroach allergens in ethnically diverse populations.

METHODS

Alleles at 14 HLA region loci were studied in the Hutterites. On the basis of these results, selected loci were examined in 54 African Americans with cockroach sensitization (cases) and 65 African Americans without cockroach sensitization (controls). Sensitivity to cockroach allergens was assessed in both samples by skin prick test to purified cockroach allergens (Periplaneta americana and Blatella germanica).

RESULTS

Significant associations between cockroach allergies and DRB1*0101 (P(corrected) =.0066), DQA1*0101 (P(corrected) =.0012), and DQB1*0501 (P(corrected) =.00096) were detected in the Hutterites. In the African American sample, the most significant association was with the DRB1*0102 allele (P(corrected) =.0088, odds ratio 16.4, 95% confidence interval 2.0, 131). The DRB1*0101 allele was infrequent in the African American sample (frequency 0.06) and the DRB1*0102 allele was absent in the Hutterites. DRB1*0101 and DRB1*0102 are closely related alleles that differ from nearly all other DRB1 alleles at 3 amino acids in the 1 peptide binding domain of the HLA-DR molecule.

CONCLUSIONS

The DRB1*0101 allele in the Hutterites and the DRB1*0102 allele in African Americans confer risk for cockroach sensitization. Elucidating this interaction at the molecular level may allow for more targeted treatment and prevention of atopic asthma in inner-city populations.

Milk of calcium in the inferior calyx of a hydronephrotic kidney in a tetraplegic patient - a diagnosis to be made before scheduling for extracorporeal shock wave lithotripsy

STUDY DESIGN

A Case Report of renal milk of calcium in a tetraplegic subject.

OBJECTIVES

To increase the awareness of renal milk of calcium in spinal cord injury (SCI) physicians. Renal milk of calcium contains a colloidal suspension of calcium crystals. Since upright views of the kidneys are not performed in tetraplegic subjects, the renal milk of calcium may be misinterpreted as renal lithiasis by routine radiography taken in supine position.

SETTING

Regional Spinal Injuries Centre, Southport, England.

METHOD

In a 41-year-old male with traumatic tetraplegia, X-ray of abdomen in supine position showed multiple opacities in the region of the left kidney. These radio opaque shadows were interpreted as renal calculi. Subsequently, computed tomography (CT) of the kidneys was performed.

RESULTS

CT confirmed the presence of calculi in the mid-polar calyx. However, the density situated in the inferior calyx of the hydronephrotic left kidney exhibited a horizontal upper edge. This specific radiological finding as observed in the CT of kidneys, provided the clue to the presence of milk of calcium in the inferior calyx of the hydronephrotic left kidney.

CONCLUSION

As plain film of the abdomen in standing position is not performed in SCI patients, physicians caring for SCI patients should have a high index of suspicion for renal milk of calcium. Prompt diagnosis of renal milk of calcium will help to avoid unnecessary surgery, or extracorporeal shock wave lithotripsy.

Variation in the interleukin 4-receptor alpha gene confers susceptibility to asthma and atopy in ethnically diverse populations

After a genomewide screen in the Hutterites was completed, the IL4RA gene was examined as the 16p-linked susceptibility locus for asthma and atopy. Seven known variants and one novel variant, representing all nonsynonymous substitutions in the mature protein, were examined in the Hutterites; on the basis of studies in the Hutterites, outbred white, black, and Hispanic families were genotyped for selected markers. All population samples showed evidence of association to atopy or to asthma (P values.039-.0044 for atopy and. 029-.0000061 for asthma), but the alleles or haplotypes showing the strongest evidence differed between the groups. Overall, these data suggest that the IL4RA gene is an atopy- and asthma-susceptibility locus but that variation outside the coding region of the gene influences susceptibility.

Genome-wide screen for atopy susceptibility alleles in the Hutterites

A genome-wide screen for loci influencing positive skin prick tests (SPT) to airborne allergens was conducted in the Hutterites, a founder population of European ancestry. Positive SPT to 14 standardized allergens was measured in 370 subjects in our primary sample and 324 subjects in a replication sample. Evidence for linkage to positive SPT was assessed using the transmission disequilibrium test (TDT) with 337 autosomal markers (average spacing 9.13 cM, SD = 7.8 cM). Three loci showed the strongest overall evidence of linkage to atopy, with at least one allele-specific and a locus-specific p< 1 x 10(-4). This study provides evidence for at least three atopy-susceptibility loci in the Hutterites on chromosomes 1, 6 and 16.

Biosynthesis of the Pseudomonas polyketide coronafacic acid requires monofunctional and multifunctional polyketide synthase proteins

Coronafacic acid (CFA) is the polyketide component of the phytotoxin coronatine, a virulence factor of the plant pathogen Pseudomonas syringae. Our current knowledge of polyketide biosynthesis largely is based on the analysis of polyketide synthases (PKSs) in actinomycetes and other Gram-positive bacteria. Consequently, the cloning and characterization of the CFA biosynthetic gene cluster will contribute significantly to our knowledge of polyketide synthesis in Pseudomonas. In this report, we describe two genes in the CFA biosynthetic gene cluster that encode PKSs that are structurally and functionally similar to the multifunctional modular PKSs, which catalyze the synthesis of macrolide antibiotics. The CFA PKS genes were overproduced in Escherichia coli and shown to cross-react with antisera made to a modular PKS involved in erythromycin synthesis. A scheme for CFA biosynthesis is presented that incorporates the activities of all proteins in the CFA PKS. In this report a gene cluster encoding a pseudomonad polyketide has been completely sequenced and the deduced gene functions have been used to develop a biosynthetic scheme.

Genome-wide search for asthma susceptibility loci in a founder population. The Collaborative Study on the Genetics of Asthma

Founder populations offer many advantages for mapping genetic traits, particularly complex traits that are likely to be genetically heterogeneous. To identify genes that influence asthma and asthma-associated phenotypes, we conducted a genome-wide screen in the Hutterites, a religious isolate of European ancestry. A primary sample of 361 individuals and a replication sample of 292 individuals were evaluated for asthma phenotypes according to a standardized protocol. A genome-wide screen has been completed using 292 autosomal and three X-Y pseudoautosomal markers. Using the semi-parametric likelihood ratio chi2 test and the transmission-disequilibrium test, we identified 12 markers in 10 regions that showed possible linkage to asthma or an associated phenotype (likelihood ratio P < 0.01). Markers in four regions (5q23-31, 12q15-24.1, 19q13 and 21q21) showed possible linkage in both the primary and replication samples and have also shown linkage to asthma phenotypes in other samples; two adjacent markers in one additional region (3p24.2-22) showing possible linkage is reported for the first time in the Hutterites. The results suggest that even in founder populations with a relatively small number of independent genomes, susceptibility alleles at many loci may influence asthma phenotypes and that these susceptibility alleles are likely to be common polymorphisms in the population.

The impact of initial surgical management on outcome in young patients with differentiated thyroid cancer

BACKGROUND/PURPOSE

It is generally believed that differentiated thyroid cancer (DTC) in young patients has an excellent prognosis. This calls into question the need for more extensive surgical ablation of the thyroid gland with attendant risks of surgical complications. The purpose of this report was to investigate both the incidence of surgical morbidity and the impact of surgery on locoregional recurrence of disease.

METHODS

The authors reviewed the clinical course of patients under 22 years of age treated for DTC within Department of Defense hospitals since 1950. Data were available for determination of surgical morbidity in 126 and for outcome in 105.

RESULTS

The incidence of postoperative hypocalcemia was 17% and of recurrent laryngeal nerve injury 3%. Factors predictive of morbidity were (1) more extensive thyroid surgery (P = .023), and (2) the presence of gross tumor invasion (P = .022). The incidence of neck recurrence was analyzed among a cohort of 90 patients. A total of 19 (21%) patients had a local recurrence. The median time to recurrence was 24 months. The factor predictive of recurrence was the presence of gross invasion (P = .0001). A strong trend toward locoregional recurrence was found among patients with metastatic disease to more than five cervical nodes (P < .08). The primary operations on the thyroid and regional nodes were not significant predictors of neck recurrence. Among these 19 patients there have been no deaths, but 25% had persistent disease at a mean follow-up of 12.6 years.

CONCLUSIONS

The incidence of surgical morbidity does increase with more extensive surgery. Outcome is predicted primarily by the initial extent of disease.

Silicon and aluminium interactions in haemodialysis patients

BACKGROUND

Aluminium toxicity in dialysis patients is well described. Aluminium has a close chemical affinity with silicon. Silicon may have a role in protection against aluminium toxicity.

METHODS

We measured serum aluminium and silicon levels from haemodialysis patients from four different centres.

RESULTS

Though no relationship was seen across all centres combined, in one centre there was a reciprocal relationship in patients on home haemodialysis (who did not require reverse osmosis). Median (range) aluminium levels were higher, 2.2 (0.4-9.6) micromol/l when serum silicon was less than 150 micromol/l, and lower, 1.1 (0.2-2.8) micromol/l when serum silicon levels were greater than 150 micromol/l (P = 0.03).

CONCLUSIONS

In patients treated by haemodialysis without reverse osmosis high serum silicon concentrations were associated with lower serum aluminium concentrations than those with low serum silicon. Further work needs to confirm a preventative role for silicon in the accumulation and subsequent toxicity of aluminium in dialysis patients.

Expression and analysis of coronafacate ligase, a thermoregulated gene required for production of the phytotoxin coronatine in Pseudomonas syringae

Coronafacic acid, the polyketide component of the phytotoxin coronatine, is activated and coupled to coronamic acid via amide bond formation, a biosynthetic step presumably catalyzed by the coronafacate ligase (cfl) gene product. In the present study, cfl was fused to the carboxy terminus of malE, which encodes the maltose-binding protein (MBP), and overexpressed in Escherichia coli. Immunoblot analysis indicated that Cfl contained an ATP-binding region, a motif conserved in enzymes which activate their substrates by adenylation. MBP-Cfl was overproduced and purified from Pseudomonas syringae and the protein fusion was used to generate antisera. Anti-MBP-Cfl antibodies and a transcriptional fusion of the cfl promoter to a promoterless glucuronidase gene were used to follow the temporal expression of coronafacate ligase. The results indicated that transcription of cfl is temperature-sensitive. Furthermore, a nonpolar mutation in cfl suggested that the gene may have a role in coronafacic acid biosynthesis.

How enrolled nurses feel about conversion

Enrolled nurses work in a state of uncertainty. EN training ended in 1992 and health care assistants with NVQs are being employed in many areas. The UKCC's Rule 18, which sets out the scope of practice for ENs, is now under review. This article gives the results of a survey of ENs who have undertaken conversion to RGN.

Inhibition of sperm-zona binding by suramin, a potential 'lead' compound for design of new anti-fertility agents

Progress in developing new contraceptive agents, particularly for the male, is extremely slow. Here, we report on a novel property of the anti-trypanosomal drug suramin: the ability to act at the sperm-egg interface and prevent fertilization. Suramin is a polysulphonated compound that inhibits binding of capacitated mouse spermatozoa to the zona pellucida in vitro with an IC50 of 12.4 microM. The drug is only effective at the time of fertilization and is not inhibitory if gametes are pre-treated separately. Autoradiographic localization of suramin binding sites on mouse, boar and human spermatozoa shows that they are intracellular, principally in the head region. The sperm protein recognized by suramin has been identified as proacrosin which is known to interact with sulphate groups on zona glycoproteins. Zona pellucida glycoproteins do not bind suramin, suggesting that the drug blocks the ability of proacrosin/acrosin, exposed during the acrosome reaction, to mediate the secondary binding phase of spermatozoa to the zona during fertilization. Structure-based design studies have the potential to generate safe suramin mimetics that would form the basis for a new generation of non-steroidal contraceptive agents.

ANCA-associated vasculitis: diagnosis and treatment in the elderly

We report the successful treatment of three patients with ANCA-associated vasculitis aged 79, 80, and 80 years. We also review other published reports of treatment in the elderly and discuss complications of treatment with emphasis on elderly patients.

Evaluation of distal run-off before femorodistal bypass

The quality of distal run-off is one of the most important factors in determining outcome of femorodistal bypass. Accurate evaluation is important. Preoperative intra-arterial digital subtraction angiography and Doppler evaluation with pulse-generated augmentation of 90 patients who underwent femorodistal reconstruction were compared with postoperative angiography. Underestimation of distal run-off of the calf vessels occurred in 33% of cases by preoperative intra-arterial digital subtraction angiography. A below-knee pulse-generated run-off score of 3 or less was associated with a 12-month cumulative patency of 73% compared with 85% with a below-knee pulse-generated run-off score of 4 or more (P=0.079, log rank test; P =0.060, Wilcoxon signed rank test). The 12-month cumulative patency for grafts with a complete, incomplete and occluded arch as defined by pulse-generated run-off was 78, 90 and 38% respectively (P<0.0001 log rank and Wilcoxon signed rank tests). Preoperative evaluation of distal run-off before femorodistal bypass should not be based exclusively on intra-arterial digital subtraction angiography.

Chaos under canvas: a Salmonella enteritidis PT 6B outbreak

An outbreak of Salmonella enteritidis PT 6B food poisoning, the first reported of this recently described phage type, resulted in illness among 46 of 49 members of a camping group in North Wales, 33 of whom were hospitalized. Epidemiological evidence (P < 0.0001) indicated that a lemon meringue pie was the vehicle of infection. Fresh shell eggs, stored after purchase at ambient temperature, appear to be the most likely source of infection, with multiplication during preparation and subsequent storage of the pie a significant contributory factor. Campers may be at greater risk than others and should consider the use of cold boxes for the transport and storage of eggs, and avoid the preparation of lightly cooked egg products under these basic conditions.