Surveillance system integration: reporting the results of a global multicountry survey

OBJECTIVES

Currently, there is no comprehensive picture of the global surveillance landscape. This survey examines the current state of surveillance systems, levels of integration, barriers and opportunities for the integration of surveillance systems at the country level, and the role of national public health institutes (NPHIs).

STUDY DESIGN

This was a cross-sectional survey of NPHIs.

METHODS

A web-based survey questionnaire was disseminated to 110 NPHIs in 95 countries between July and August 2022. Data were descriptively analysed, stratified by World Health Organization region, World Bank Income Group, and self-reported Integrated Disease Surveillance (IDS) maturity status.

RESULTS

Sixty-five NPHIs responded. Systems exist to monitor notifiable diseases and vaccination coverage, but less so for private, pharmaceutical, and food safety sectors. While Ministries of Health usually lead surveillance, in many countries, NPHIs are also involved. Most countries report having partially developed IDS. Surveillance data are frequently inaccessible to the lead public health agency and seldomly integrated into a national public health surveillance system. Common challenges to establishing IDS include information technology system issues, financial constraints, data sharing and ownership limitations, workforce capacity gaps, and data availability.

CONCLUSIONS

Public health surveillance systems across the globe, although built on similar principles, are at different levels of maturity but face similar developmental challenges. Leadership, ownership and governance, supporting legal mandates and regulations, as well as adherence to mandates, and enforcement of regulations are critical components of effective surveillance. In many countries, NPHIs play a significant role in integrated disease surveillance.

Opening a can of worms: Archived canned fish fillets reveal 40 years of change in parasite burden for four Alaskan salmon species

How has parasitism changed for Alaskan salmon over the past several decades? Parasitological assessments of salmon are inconsistent across time, and though parasite data are sometimes noted when processing fillets for the market, those data are not retained for more than a few years. The landscape of parasite risk is changing for salmon, and long-term data are needed to quantify this change. Parasitic nematodes of the family Anisakidae (anisakids) use salmonid fishes as intermediate or paratenic hosts in life cycles that terminate in marine mammal definitive hosts. Alaskan marine mammals have been protected since the 1970s, and as populations recover, the density of definitive hosts in this region has increased. To assess whether the anisakid burden has changed in salmonids over time, we used a novel data source: salmon that were caught, canned, and thermally processed for human consumption in Alaska, USA. We examined canned fillets of chum (Oncorhynchus keta, n = 42), coho (Oncorhynchus kisutch, n = 22), pink (Oncorhynchus gorbuscha, n = 62), and sockeye salmon (Oncorhynchus nerka, n = 52) processed between 1979 and 2019. We dissected each fillet and quantified the number of worms per gram of salmon tissue. Anisakid burden increased over time in chum and pink salmon, but there was no change in sockeye or coho salmon. This difference may be due to differences in the prey preferences of each species, or to differences in the parasite species detected across hosts. Canned fish serve as a window into the past, providing information that would otherwise be lost, including information on changes over time in the parasite burden of commercially, culturally, and ecologically important fish species.

A262 NEONATAL ACUTE LIVER FAILURE DUE TO PRESUMED GESTATIONAL ALLOIMMUNE LIVER DISEASE - A CASE REPORT

Background

Neonatal acute liver failure (NALF) is a rare disease that is distinct from acute liver failure seen in older children and adults. Gestational alloimmune liver disease (GALD) is the most frequent cause, is initiated in utero by sensitization of the maternal immune system to a fetal hepatocyte antigen and subsequent production of maternal immunoglobulin G antibodies that cross the placenta. Maternal IgG binds to a fetal hepatocyte antigen and initiates an innate immune response involving the terminal complement cascade and membrane attach complex. The understanding of the alloimmune origin has led to the use of intravenous immunoglobulin (IVIG) treatment and exchange transfusion, significantly increasing survival. However, approximately 25% of patients may not respond and require salvage liver transplantation. In spite of an increased rate of comorbidities, concern for technical difficulties and limited graft availability, young infants eligible for transplant have been shown to have similar overall patient and graft survival rates compared to older children with other indications for liver transplant.

Purpose

The primary aim of our study is to report a case of NALF with successful liver transplant.

Method

We present the case of a preterm girl with NALF due to GALD refractory to medical management, requiring liver transplantation.

Result(s)

This is a 35-week preterm girl, with scant pre-natal care, birth weight of 1.825 kg and Apgar 9/9. She is the seventh child of non-consanguineous parents, with healthy siblings. On day-of-life (DOL) 1 she presented with acute kidney injury, progressive worsening metabolic acidosis and hyperammonemia and was found to be profoundly coagulopathic (INR 6), with normal liver enzymes and liver failure was diagnosed. Initial investigation ruled out congenital infections, sepsis, neonatal hemophagocytic lymphohistiocytosis and metabolic diseases. Magnetic resonance imaging of the body demonstrated findings in keeping with iron deposition in the thyroid, liver and pancreas, suggestive of GALD. Completed double volume exchange transfusion and IVIG on DOL 9 and repeat IVIG on DOL 13 and 15, with partial improvement in INR. Due to persistent ascites, conjugated hyperbilirubinemia and hyperammonemia she was transferred for urgent liver transplant assessment. Persistent liver dysfunction in the form of hyperammonemia, hypoglycemia and progressive coagulopathy led to transplant listing on DOL 30. ABO incompatible deceased donor liver transplant was completed on DOL 62 (4.075 kg, estimated dry weight 3.5 kg). The procedure was uncomplicated, liver enzymes normalized, coagulopathy and hypoglycemia resolved. She was transferred to the ward on post-operative day (POD) 6. and weaned off sedatives and transitioned to oral feeds within 2 weeks of transplant, with complex abdominal wound closure on POD 29.

Conclusion(s)

Successful liver transplantation is possible in neonates with acute liver failure due to GALD refractory to medical management and weighing 4kg or less.

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None

Disclosure of Interest

None Declared

MICROBIOME & MICROBIAL THERAPY

A258 SEVERE ACUTE HEPATITIS OF UNKNOWN ORIGIN WITH RAPID PROGRESSION TO PAEDIATRIC ACUTE LIVER FAILURE IN A CHILD

Background

Severe acute hepatitis (SAH) of unknown origin among children has been a major public health concern globally in recent times, with >1010 cases reported to WHO, including 28 in Canada as of July2022. The clinical syndrome in all identified cases (median age 3, IQR 2-5 yrs) was acute hepatitis with progression to paediatric acute liver failure (PALF) and need for liver transplantation (LT) in 5.4-13%. Human adenovirus (HAdV), particularly serotypes 40 and 41, remains the most common pathogen detected around the time of presentation in upto 70%. HAdV hepatitis is a rarity in the immunocompetent. The role of adenovirus in SAH remains unclear and investigations continue

Purpose

To report the case of a child meeting the WHO case definition of SAH of unknown origin in whom adenovirus was detected with rapid progression to PALF requiring LT

Method

Case report and literature review

Result(s)

A previously healthy 4year-old girl presented to us with a 1week history of abdominal pain and vomiting followed by onset of jaundice. 1month prior to presentation, she had an episode of conjunctivitis. Examination revealed a well-appearing girl with icterus, hepatosplenomegaly with no stigmata of chronic liver disease and no features of hepatic encephalopathy. Laboratory results on day of presentation revealed transaminases >10 times upper limit of normal (ALT 4686U/L, AST 5986U/L), total bilirubin-233μmol/L (conjugated bilirubin-153μmol/L) and INR-1.6. Work up for viral hepatitis(A-E), metabolic, autoimmune, genetic or mechanical causes of hepatitis was negative (Table 1). HAdV was detected by PCR in blood (9700 copies/mL), stool and nasopharyngeal swab. Treatment with cidofovir (1mg/kg/dose) was started on day8 after presentation.By day11, laboratory parameters had worsened with ALT 1293U/L, AST 2326U/L, total bilirubin 331μmol/L, INR-9.1 and LT was considered. With failure to improve over the next 48hrs, she received a living donor LT on day13 after presentation and had an uneventful post-transplant course. At the time of writing this report, she was 41 days post-transplant, doing well on immunosuppression with tacrolimus and tapering dose of steroids. Histopathological examination of liver showed extensive hepatocyte loss of upto 80%, replaced by ductules, in a background of mild hepatitis (patchy pan-lobular inflammation with minimal portal inflammation) and no significant fibrosis. Electron microscopy (EM) showed patchy hemophagocytosis. No evidence of HAdV on immunohistochemical stains or EM was identified. These findings are directly in line with what others have reported, namely a lack of direct toxic effect of virus on liver tissue

Image

Conclusion(s)

This case highlights the potential for rapid progression to PALF and need for LT in a child SAH of unknown origin. Early identification and diagnosis of PALF is important and should be followed by transfer to a LT center. As previously described by others, HAdV was detected, but its role in pathogenesis of this clinical syndrome remains elusive

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Disclosure of Interest

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Impact of regurgitant orifice ellipticity on quantitation of tricuspid regurgitation using the proximal isovelocity surface area method

Funding Acknowledgements

Type of funding sources: None.

Background

The proximal isovelocity surface area (PISA) method to quantify tricuspid regurgitation (TR) severity relies on the geometric assumption of a circular, planar regurgitant orifice.  However, the TR orifice is often non-circular resulting in underestimation of TR severity when calculating the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol).

Purpose

To evaluate the effect of ellipticity of the tricuspid annulus on EROA-PISA correlation with quantitative Doppler (EROA-Dopp), and three-dimensional vena contracta area (VCA-3D).

Methods

Patients undergoing both transthoracic (TTE) and transesophageal (TEE) echo evaluation of TR severity were included in this study. Regurgitant orifice ellipticity was calculated as the ratio of the vena contracta maximum and minimum widths (VC-Ratio). Quantification of EROA and RegVol were performed on TTE for EROA-PISA and EROA-Dopp. Vena contract area was measured on TEE (VCA-3D).

Results

Of 44 total pts, the median age was 80 ± 9, 61% were female, 89% had atrial fibrillation, (86%) had functional TR, 32% were graded as severe, and 71% had a EROA-PISA ≥ 0.4 cm2. Median VC-Ratio was 1.3 (IQR 1.1-1.8) and was used to differentiate more circular orifices (VC-Ratio <1.3) from more elliptical orifices (VC-Ratio ≥1.3) (Table). EROA-PISA was significantly smaller compared to EROA-Dopp and VCA-3D in the whole group as well as elliptical subgroups (p < 0.0001 for all).  There was no significant difference between EROA-Dopp and 3D-VCA for the whole group, or in circular or elliptical orifice subgroups (p > 0.5 for all). EROA-PISA correlated better with both EROA-Dopp and VCA-3D in circular compared to elliptical orifices (Table). EROA-Dopp and VCA-3D demonstrated high correlation for both circular and elliptical orifices (r = 0.76, p < 0.0001 and r = 0.77, p < 0.0001 respectively).

Conclusion

Our study demonstrated that there is a significant difference in quantitative measurements of tricuspid regurgitant orifice area, with EROA-PISA significantly underestimating both EROA-Dopp and VCA-3D.  In more circular orifices, the EROA-PISA correlation was higher, however EROA-Dopp and VCA-3D were still significantly larger. Whether EROA-Dopp and VCA-3D are more predictive of outcomes requires further study. Abstract Table 1  Abstract Figure 1

Correlation between standard and adjusted echocardiographic quantitative methods for evaluating tricuspid regurgitation severity

Funding Acknowledgements

Type of funding sources: None.

Background

Current guidelines advocate for a multi-parametric approach to echocardiographic quantitation of tricuspid regurgitation (TR). The primary quantitative measure of TR severity uses the proximal isovelocity surface area (PISA) method to calculate effective regurgitant orifice area (EROA) and regurgitant volume (RegVol). However, EROA-PISA may underestimate TR severity due to low flow and tethering of the tricuspid leaflets.

Purpose

The purpose of this study was to compare standard EROA-PISA quantitation of TR to alternative quantitative measures, including quantitative Doppler (EROA-Doppler), flow- and angle-corrected PISA method (EROA-Corrected), and three-dimensional vena contracta area (3D-VCA), in addition to the comparison of calculated RegVol-PISA, RegVol-Doppler, and RegVol-3DVCA.

Methods

Patients undergoing both transthoracic (TTE) and transesophageal (TEE) echocardiographic evaluation of TR severity for transcatheter treatment were included in this study. Patients were excluded if they had ≥ moderate aortic regurgitation. TTE measurements of EROA-PISA and RegVol-PISA were performed as per American Society of Echocardiography guidelines. EROA-Doppler was performed by quantifying RegVol-Doppler (diastolic stroke volume using biplane annular area, minus left ventricular outflow stroke volume) and deriving EROA. EROA-Corrected was calculated by adjusting for both aliasing velocity and leaflet angle as per published methods. 3D-VCA was measured on TEE performed within 14 days of TTE.

Results

Of 44 consecutive patients, the median age was 80 ± 9 years, 61% were female, and 89% had atrial fibrillation. Most patients (86%) had functional TR, 71% had a EROA-PISA ≥ 0.4 cm2. Table 1 shows the EROA and RegVol results for each method.  EROA-PISA and RegVol-PISA were significantly lower than EROA-Doppler and RegVol-Doppler, as well as 3D-VCA and RegVol-3DVCA (all p < 0.0001). There was no significant difference between EROA-Doppler and 3D-VCA (p = 0.51), and RegVol-Doppler and RegVol-3DVCA (p = 0.66).  EROA-Corrected reduced the absolute difference with EROA-Doppler (51% to 33%, p < 0.0001) and 3D-VCA (52% to 32%, p < 0.0001), but remained statistically lower than EROA-Doppler and 3D-VCA. Although EROA-PISA was strongly correlated to EROA-Doppler (r = 0.75, p < 0.0001) and 3D-VCA (r = 0.68, p < 0.0001), the correlation between EROA-Doppler and 3D-VCA was greatest (r = 0.77, p < 0.0001). Adjusting EROA-PISA for angle and flow demonstrated improved correlation to EROA-Doppler without affecting correlation to 3D-VCA (Figure 1).

Conclusion

Our study demonstrated that EROA-PISA significantly underestimates the severity of TR by EROA-Doppler and 3D-VCA. Although PISA correction methods reduced the underestimation, both EROA-Corrected and RegVol-Corrected remained significantly lower. EROA-Doppler and 3D-VCA and the calculated RegVol by each method, were closely correlated and not significantly different. Abstract Table 1  Abstract Figure 1

625 Health Economics and Safety of Frontline Carers in the COVID-19 Era: Time to Abolish Routine Group and Save For Emergency Appendicectomies?

Introduction

Face of healthcare, patient safety and protection of healthcare providers has been completely transformed with global health pandemic. However, emergency surgical procedures must still be performed, with the commonest being appendicectomy.

It is common practice across National Health Service trusts to collect a group and save (G&S) sample pre-operatively which increases healthcare staff exposure to the patient and increased use of personal protective equipment in this pandemic.

Method

Prospective study of adult patients undergoing emergency appendicectomy since the transformation of emergency care with COVID-19 induced restrictions compared with patients undergoing the same operation before the pandemic.

Results

179 adult patients underwent emergency appendicectomy over 6-months in 2019–2020, 60 patients in the 12 weeks period from the start of the transformed emergency services due to the pandemic. Pre-operative G&S samples were taken for 60(33.5%) patients in the pre COVID-19 period, whereas 7(11.6%) were taken for patients undergoing appendicectomy during the pandemic. None of the patients in either group had intra-operative blood loss of more than 500 millilitres and none of them required peri-operative blood transfusion

Conclusions

Our study demonstrates that the routine pre-operative G&S can safely be abandoned as a routine practice for all patients undergoing emergency appendicectomy.

A215 MDR3 DEFICIENCY MIMICKING WILSON DISEASE

Background

The chronic phenotype of ALF includes a broad differential diagnosis. Class III multi-drug resistance P-glycoprotein 3 (MDR3) deficiency, also referred to as progressive familial intrahepatic cholestasis type 3, is an autosomal recessive genetic disorder. It is caused by a defect on the ABCB4 gene located on chromosome 7, which encodes MDR3. MDR3 is responsible for transporting phosphatidylcholine across the canalicular membrane, thereby allowing it to be incorporated into bile micelles. MDR3 deficiency results in increased levels of free bile acids and detergent bile. Progressive cholangiopathy ensues from this detergent bile and indirectly leads to cholestasis and liver failure in severe cases. Significantly increased urinary and hepatic copper (Cu), which are hallmarks of Wilson disease, have also been reported in patients with acute hepatitis and cholestasis including patients with MDR3 deficiency

Aims

We report a case of a girl who presented with a chronic phenotype of PALF, who had multiple features of Wilson disease and so was treated as such until genetic analysis confirmed MDR3 deficiency

Methods

Results

A 6 year old girl presented to the ED with a 1mth history of epistaxis and a 1wk history of abdominal pain and distension, facial edema, pallor and fever. Her family history was significant for parental consanguinity and maternal itch during pregnancy. On examination she had clubbing, scleral icterus and a distended abdomen with hepatosplenomegaly. Her bloodwork showed bicytopenia (HGB 53 & Plts 63) along with liver dysfunction (INR 2.9, albumin 25, conjugated bilirubin 9) and raised liver enzymes (transaminases & GGT >10xULN). Her total serum bile acids were raised at 134. An US showed hepatosplenomegaly with multiple hyperechoic nodules and perisplenic varices. She was extensively worked up for malignancy, autoimmune and metabolic disease. Serum ceruloplasmin was reduced, ophthalmology examination showed no KF rings and her 24hr urinary Cu was 10xULN. Liver Cu quantification was markedly raised at 40xULN. Liver biopsy showed cirrhosis with fibrosis related minimal non-specific portal and septal inflammation. Additionally, complete loss of canalicular staining on immunohistochemistry for MDR3 protein was noted, suggestive of MDR3 deficiency. Based on the Cu levels, a provisional diagnosis of Wilson disease was made and Cu chelation therapy was commenced pending genetic testing. A cholestatic gene panel subsequently showed homozygous pathogenic variant for the ABCB4 gene. Trientine was stopped and she was commenced on ursodeoxycholic acid. Though biochemically she remains largely unchanged, she is clinically stable whilst awaiting a liver transplant

Conclusions

This case highlights the diagnostic difficulties associated with Cu test result interpretation in patients with chronic cholestatic liver disease and urges a thorough consideration of alternative diagnoses of PALF

Funding Agencies

None

Cavum septum pellucidum and adhesio interthalamica in schizophrenia: an MRI study

Several studies have independently suggested that patients with schizophrenia are more likely to have an enlarged cavum septum pellucidum (CSP) and an absent adhesio interthalamica (AI), respectively. However, neither finding has been consistently replicated and it is unclear whether there is an association between these two midline brain abnormalities. Thus, we compared the prevalence of absent AI and the prevalence, size and volume of CSP in 38 patients with schizophrenia and 38 healthy controls using magnetic resonance imaging (MRI). There were no between group differences in the presence or volume of CSP; however, an enlarged CSP was commoner among patients than controls. There was also a positive correlation between CSP ratings and volumes. No differences in the presence or absence of the AI were found between patients and controls; however, an absent AI was commoner in male patients with schizophrenia than females. There was absolutely no overlap between the presence of a large CSP and an absence of AI. In conclusion, our findings are in line with several case series and other MRI investigations that have shown a higher incidence of putatively developmental brain abnormalities in patients with schizophrenia, particularly in males, and support the neurodevelopmental model of this disorder.

A57 VALPROATE INDUCED DRESS SYNDROME CAUSING MIXED LIVER INJURY

Background

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome occurs with 1 in every 1,000 to 10,000 drug exposures and has a mortality rate of up to 10%. It is one mechanism by which medications can induce liver injury with elevated liver enzymes seen in the majority of cases. In children, aromatic anticonvulsants are the drugs most commonly associated with DRESS syndrome. Valproate, a non-aromatic anti-epileptic, is not known to have a heightened risk of hypersensitivity syndromes and is often the anti-epileptic of choice in patients who develop hypersensitivity syndromes from other anti-epileptics. Valproate hepatotoxicity is normally caused by its inhibition of fatty acid transport and mitochondrial β-oxidation; vanishing bile duct syndrome is also reported.

Aims

We present a case, to the best of our knowledge the first in paediatrics, in which valproate causes DRESS syndrome and a secondary, predominantly cholestatic, liver injury.

Methods

Literature review and case report.

Results

A previously healthy 14-year-old girl was diagnosed with new-onset seizures and started on valproate. Three weeks later, she developed a pruritic exanthem. Despite discontinuing her valproate, the rash persisted and she developed fever and jaundice. She was admitted to the ICU at the Hospital for Sick Children with a diagnosis of DRESS syndrome (RegiSCAR DRESS score 7) for treatment with IV steroids. At admission, she had a skin eruption, fever, leukocytosis (22.86 x109/L), eosinophilia (1.03x109/L), atypical lymphocytes (1.62 x109/L), lymphadenopathy, and internal organ involvement (BiliC 138, GGT 501, INR 1.3, ALT 543, AST 370, Crt 109). Of note, her EBV PCR was positive. By discharge, her rash improved and kidney function normalized. Her cholestasis persisted, despite improvement in her transaminases and eosinophilia (BiliC 163, INR 1.0, GGT 338, ALT 506, AST 220, Eos 0.98x109/L). She was discharged home on an oral steroid wean, ursodeoxycholic acid, levocarnitine, and levetiracetam. Upon reaching a daily dose of 20mg of prednisone, her rash and pruritus worsened, she had lost 7kg, and she was readmitted for IV steroids. Her rash improved within 4 days and she was discharged on a slower steroid taper, with the addition of cholestyramine and insulin for steroid induced diabetes. At present (2 ½ months after diagnosis), she continues her oral steroids and has persistent liver injury and pruritus.

Conclusions

We report the first paediatric case of valproate induced DRESS syndrome causing a significant cholestatic presentation with otherwise preserved liver synthetic function. The prolonged cholestasis and pruritus may be a result of the natural course of DRESS syndrome, EBV reactivation/infection, or polypharmacy. Early recognition of DRESS syndrome as a mechanism of valproate induced liver injury in children is essential for earlier diagnosis and initiation of targeted therapy.

Funding Agencies

None

Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

Influenza increases invasive meningococcal disease risk in temperate countries

OBJECTIVES

Invasive meningococcal disease (IMD) is a severe bacterial infection that displays wintertime seasonality in temperate countries. Mechanisms driving seasonality are poorly understood and may include environmental conditions and/or respiratory virus infections. We evaluated the contribution of influenza and environmental conditions to IMD risk, using standardized methodology, across multiple geographical regions.

METHODS

We evaluated 3276 IMD cases occurring between January 1999 and December 2011 in 11 jurisdictions in Australia, Canada, France and the United States. Effects of environmental exposures and normalized weekly influenza activity on IMD risk were evaluated using a case-crossover design. Meta-analytic methods were used to evaluate homogeneity of effects and to identify sources of between-region heterogeneity.

RESULTS

After adjustment for environmental factors, elevated influenza activity at a 2-week lag was associated with increased IMD risk (adjusted odds ratio (OR) per standard deviation increase 1.29; 95% confidence interval, 1.04-1.59). This increase was homogeneous across the jurisdictions studied. By contrast, although associations between environmental exposures and IMD were identified in individual jurisdictions, none was generalizable.

CONCLUSIONS

Using a self-matched design that adjusts for both coseasonality and case characteristics, we found that surges in influenza activity result in an acute increase in population-level IMD risk. This effect is seen across diverse geographic regions in North America, France and Australia. The impact of influenza infection on downstream meningococcal risk should be considered a potential benefit of influenza immunization programmes.

Risk assessment strategies for early detection and prediction of infectious disease outbreaks associated with climate change

A new generation of surveillance strategies is being developed to help detect emerging infections and to identify the increased risks of infectious disease outbreaks that are expected to occur with climate change. These surveillance strategies include event-based surveillance (EBS) systems and risk modelling. The EBS systems use open-source internet data, such as media reports, official reports, and social media (such as Twitter) to detect evidence of an emerging threat, and can be used in conjunction with conventional surveillance systems to enhance early warning of public health threats. More recently, EBS systems include artificial intelligence applications such machine learning and natural language processing to increase the speed, capacity and accuracy of filtering, classifying and analysing health-related internet data. Risk modelling uses statistical and mathematical methods to assess the severity of disease emergence and spread given factors about the host (e.g. number of reported cases), pathogen (e.g. pathogenicity) and environment (e.g. climate suitability for reservoir populations). The types of data in these models are expanding to include health-related information from open-source internet data and information on mobility patterns of humans and goods. This information is helping to identify susceptible populations and predict the pathways from which infections might spread into new areas and new countries. As a powerful addition to traditional surveillance strategies that identify what has already happened, it is anticipated that EBS systems and risk modelling will increasingly be used to inform public health actions to prevent, detect and mitigate the climate change increases in infectious diseases.

Could exotic mosquito-borne diseases emerge in Canada with climate change?

Of the 3,500 species of mosquitoes worldwide, only a small portion carry and transmit the mosquito-borne diseases (MBDs) that cause approximately half a million deaths annually worldwide. The most common exotic MBDs, such as malaria and dengue, are not currently established in Canada, in part because of our relatively harsh climate; however, this situation could evolve with climate change. Mosquitoes native to Canada may become infected with new pathogens and move into new regions within Canada. In addition, new mosquito species may move into Canada from other countries, and these exotic species may bring exotic MBDs as well. With high levels of international travel, including to locations with exotic MBDs, there will be more travel-acquired cases of MBDs. With climate change, there is the potential for exotic mosquito populations to become established in Canada. There is already a small area of Canada where exotic Aedes mosquitoes have become established although, to date, there is no evidence that these carry any exotic (or already endemic) MBDs. The increased risks of spreading MBDs, or introducing exotic MBDs, will need a careful clinical and public health response. Clinicians will need to maintain a high level of awareness of current trends, to promote mosquito bite prevention strategies, and to know the laboratory tests needed for early detection and when to report laboratory results to public health. Public health efforts will need to focus on ongoing active surveillance, public and professional awareness and mosquito control. Canadians need to be aware of the risks of acquiring exotic MBDs while travelling abroad as well as the risk that they could serve as a potential route of introduction for exotic MBDs into Canada when they return home.

Does Spanish instruction for emergency medicine resident physicians improve patient satisfaction in the emergency department and adherence to medical recommendations?

BACKGROUND

After emergency department (ED) discharge, Spanish-speaking patients with limited English proficiency are less likely than English-proficient patients to be adherent to medical recommendations and are more likely to be dissatisfied with their visit.

OBJECTIVES

To determine if integrating a longitudinal medical Spanish and cultural competency curriculum into emergency medicine residency didactics improves patient satisfaction and adherence to medical recommendations in Spanish-speaking patients with limited English proficiency.

METHODS

Our ED has two Emergency Medicine Residency Programs, University Campus (UC) and South Campus (SC). SC program incorporates a medical Spanish and cultural competency curriculum into their didactics. Real-time Spanish surveys were collected at SC ED on patients who self-identified as primarily Spanish-speaking during registration and who were treated by resident physicians from both residency programs. Surveys assessed whether the treating resident physician communicated in the patient's native Spanish language. Follow-up phone calls assessed patient satisfaction and adherence to discharge instructions.

RESULTS

Sixty-three patients self-identified as primarily Spanish-speaking from August 2014 to July 2015 and were initially included in this pilot study. Complete outcome data were available for 55 patients. Overall, resident physicians spoke Spanish 58% of the time. SC resident physicians spoke Spanish with 66% of the patients versus 45% for UC resident physicians. Patients rated resident physician Spanish ability as very good in 13% of encounters - 17% for SC versus 5% for UC. Patient satisfaction with their ED visit was rated as very good in 35% of encounters - 40% for SC resident physicians versus 25% for UC resident physicians. Of the 13 patients for whom Spanish was the language used during the medical encounter who followed medical recommendations, ten (77%) of these encounters were with SC resident physicians and three (23%) encounters were with UC resident physicians.

CONCLUSION

Preliminary data suggest that incorporating Spanish language and cultural competency into residency training has an overall beneficial effect on patient satisfaction and adherence to medical recommendations in Spanish-speaking patients with limited English proficiency.

Stressful Life Events of Dental Students and Salivary Immunoglobulin A

To study the perceived sources of stressful events in dental students and the relationships between their self-perceived stress levels and salivary IgA. Undergraduates as well as postgraduates at the Faculty of Dentistry, National University of Singapore were surveyed one month after the new term. A 38-item dental environmental stress (DES) questionnaire, with subscales of academic work (AW), clinical factors (CF), faculty and administration factors (FA) and personal factors (PF), was used to identify the potential stressors in the dental environment. A 4-point perceived stress scale was used to rank their self-perceived stress levels. Enzyme linked immunosorbent assay method was used to determine the salivary IgA level. One hundred and thirty students (81.3% - valid response rate) participated in the study. Overall, students ranked AW with the highest score (mean 2.76), followed by CF (2.67), FA (2.24) and PF (2.16). Among the 38 items of DES questionnaire, 1st year students perceived “fear of being unable to catch up if behind” as the most stressful event (mean 3.30). For 2nd and 3rd year students, examination and grades had the highest scores (mean 3.28, 3.19, respectively). Completing graduation requirements was the most important stressor for 4th year students (mean 3.89). Postgraduates perceived atmosphere created by clinical faculty was most stressful to them (mean 3.05). The mean total perceived stress scores were highest (22.1) in 1st year students and lowest (21.0) in postgraduates, however, no significant different among various classes. First year students had the lowest IgA secretion rates (geometric mean [GM] 46.8 μg/min), significantly lower (p<0.05) than postgraduates (GM 79.4 μg/min). An inverse correlation was noted between perceived stress scale and log IgA secretion rates (r=-0.20, p=0.002.). AW was also significantly inversely correlated with salivary IgA (r=-0.18, p=0.04). Dental students in different academic years perceived different important stressors. Salivary IgA secretion rate correlated inversely with self perceived stress.

Prioritizing Zoonotic Diseases: Differences in Perspectives Between Human and Animal Health Professionals in North America

Zoonoses pose a significant burden of illness in North America. Zoonoses represent an additional threat to public health because the natural reservoirs are often animals, particularly wildlife, thus eluding control efforts such as quarantine, vaccination and social distancing. As there are limited resources available, it is necessary to prioritize diseases in order to allocate resources to those posing the greatest public health threat. Many studies have attempted to prioritize zoonoses, but challenges exist. This study uses a quantitative approach, conjoint analysis (CA), to overcome some limitations of traditional disease prioritization exercises. We used CA to conduct a zoonoses prioritization study involving a range of human and animal health professionals across North America; these included epidemiologists, public health practitioners, research scientists, physicians, veterinarians, laboratory technicians and nurses. A total of 699 human health professionals (HHP) and 585 animal health professionals (AHP) participated in this study. We used CA to prioritize 62 zoonotic diseases using 21 criteria. Our findings suggest CA can be used to produce reasonable criteria scores for disease prioritization. The fitted models were satisfactory for both groups with a slightly better fit for AHP compared to HHP (84.4% certainty fit versus 83.6%). Human-related criteria were more influential for HHP in their decision to prioritize zoonoses, while animal-related criteria were more influential for AHP resulting in different disease priority lists. While the differences were not statistically significant, a difference of one or two ranks could be considered important for some individuals. A potential solution to address the varying opinions is discussed. The scientific framework for disease prioritization presented can be revised on a regular basis by updating disease criteria to reflect diseases as they evolve over time; such a framework is of value allowing diseases of highest impact to be identified routinely for resource allocation.

Abstract OT1-03-06: LORELEI: A phase II randomized, double-blind study of neoadjuvant letrozole plus taselisib (GDC-0032) versus letrozole plus placebo in postmenopausal women with ER-positive/ HER2-negative, early-stage breast cancer

Background: Taselisib is an orally bioavailable, potent, selective inhibitor of Class I PI3-kinase (PI3K) alpha, gamma, and delta isoforms, with 30-fold less inhibition of the PI3K beta isoform relative to the alpha isoform showing enhanced activity against PIK3CA mutant cancer cell lines. Clinical data have demonstrated confirmed partial responses in patients with PIK3CA mutant breast cancer (BC) treated with single-agent taselisib. Enhanced antitumor activity has been noted when taselisib is combined with either letrozole or fulvestrant in preclinical and Phase Ib clinical studies.

Methods: LORELEI is a Phase II, two-arm, randomized, double-blind, multicenter, study of neoadjuvant letrozole and taselisib versus letrozole and placebo in postmenopausal women with newly diagnosed ER+/HER2-, untreated, Stage I-III operable BC. Other eligibility criteria include tumor size  2 cm by magnetic resonance imaging (MRI), ECOG PS 0-1, and evaluable tumor tissue for PIK3CA genotyping. Patients treated with anti-diabetic drugs are not eligible. Patients are randomized (1:1) to receive continuous letrozole (2.5 mg) with either taselisib (4 mg on a 5 days on/ 2 days off schedule) or placebo for 16 weeks, followed by surgery. Stratification is based on tumor size and nodal status. The co-primary endpoints are overall objective response rate (ORR) by centrally assessed breast MRI via modified RECIST criteria and pathologic complete response (pCR) rate in breast and axilla at time of surgery in all randomized patients and PIK3CA mutant patients. Secondary endpoints include ORR by centrally-assessed MRI and pCR rate in PIK3CA wild-type patients. The sample size was calculated to detect an absolute percentage increase of 24% in ORR with 80% power and an absolute percentage increase of 18% in pCR rate. An interim safety analysis will be conducted by an Independent Data Monitoring Committee. As of 1st Jun 2015, 54 of the 330 patients have been enrolled, and global enrollment is ongoing (clinicaltrials.gov NCT02273973).

Contact information:

Reference Study ID Numbers: GO28888/BIG-3-13/SOLTI 1205/ABCSG 38

Phone: 888-662-6728 (US Only)

Email Address: global.rochegenentechtrials@roche.com

Citation Format: Oliveira M, de Azambuja E, Saura C, Dubsky P, Zardavas D, Fesl C, Bardia A, Soberino J, Ciruelos Gil E, Ng V, Fredrickson J, Stout TJ, Singel SM, Hsu JY, Piccart M, Gnant M, Baselga J. LORELEI: A phase II randomized, double-blind study of neoadjuvant letrozole plus taselisib (GDC-0032) versus letrozole plus placebo in postmenopausal women with ER-positive/ HER2-negative, early-stage breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-03-06.

High Risk of Graft Failure in Emerging Adult Heart Transplant Recipients

Emerging adulthood (17-24 years) is a period of high risk for graft failure in kidney transplant. Whether a similar association exists in heart transplant recipients is unknown. We sought to estimate the relative hazards of graft failure at different current ages, compared with patients between 20 and 24 years old. We evaluated 11 473 patients recorded in the Scientific Registry of Transplant Recipients who received a first transplant at <40 years old (1988-2013) and had at least 6 months of graft function. Time-dependent Cox models were used to estimate the association between current age (time-dependent) and failure risk, adjusted for time since transplant and other potential confounders. Failure was defined as death following graft failure or retransplant; observation was censored at death with graft function. There were 2567 failures. Crude age-specific graft failure rates were highest in 21-24 year olds (4.2 per 100 person-years). Compared to individuals with the same time since transplant, 21-24 year olds had significantly higher failure rates than all other age periods except 17-20 years (HR 0.92 [95%CI 0.77, 1.09]) and 25-29 years (0.86 [0.73, 1.03]). Among young first heart transplant recipients, graft failure risks are highest in the period from 17 to 29 years of age.

Interaction of MYC with host cell factor-1 is mediated by the evolutionarily conserved Myc box IV motif

The MYC family of oncogenes encodes a set of three related transcription factors that are overexpressed in many human tumors and contribute to the cancer-related deaths of more than 70,000 Americans every year. MYC proteins drive tumorigenesis by interacting with co-factors that enable them to regulate the expression of thousands of genes linked to cell growth, proliferation, metabolism, and genome stability. One effective way to identify critical cofactors required for MYC function has been to focus on sequence motifs within MYC that are conserved throughout evolution, on the assumption that their conservation is driven by protein-protein interactions that are vital for MYC activity. In addition to their DNA-binding domains, MYC proteins carry five regions of high sequence conservation known as Myc boxes (Mb). To date, four of the Myc box motifs (MbI, MbII, MbIIIa, and MbIIIb) have had a molecular function assigned to them, but the precise role of the remaining Myc box, MbIV, and the reason for its preservation in vertebrate Myc proteins, is unknown. Here, we show that MbIV is required for the association of MYC with the abundant transcriptional coregulator host cell factor 1 (HCF-1). We show that the invariant core of MbIV resembles the tetrapeptide HCF-binding motif (HBM) found in many HCF-interaction partners, and demonstrate that MYC interacts with HCF in a manner indistinguishable from the prototypical HBM-containing protein VP16. Finally, we show that rationalized point mutations in MYC that disrupt interaction with HCF-1 attenuate the ability of MYC to drive tumorigenesis in mice. Together, these data expose a molecular function for MbIV and indicate that HCF-1 is an important co-factor for MYC.

Basiliximab with delayed introduction of calcineurin inhibitors as a renal-sparing protocol following liver transplantation in children with renal impairment

Renal impairment is frequently compromised in patients with end-stage liver disease and is associated with increased long-term mortality post-LT. In contrast to CNI, basiliximab is an immunosuppressive agent with minimal nephrotoxic potential. This study reviews the experience of a single pediatric liver transplant center's renal-sparing approach with the use of basiliximab and MMF to compensate for delayed entry of CNI in children with renal impairment at the time of organ availability. There were no differences in renal function between pediatric patients with and without pre-LT renal impairment within the first year (cGFR: 135 mL/min/1.73 m2 vs. 144 mL/min/1.73 m2 ; p = 0.56) or at 5-8 yr following LT, (129 mL/min/1.73 m2 vs. 130 mL/min/1.73 m2 ; p = 0.97). In addition, there was no difference in ACR rates (50% vs. 43%, p = 0.62) between patients in the basiliximab group and those patients receiving standard CNI and steroid strategies. The utilization of a renal-sparing approach with basiliximab alongside delayed entry and lower early target trough levels of CNI in children with renal impairment at the time of LT is safe and maintains excellent long-term kidney function.

Chronic hepatitis B virus (HBV) infection in children: 25 years' experience

Whereas e-seroconversion represents the loss of hepatitis B e-antigen (HBeAg) followed by gain of antibody to HBeAg (anti-HBe), 'inactive chronic infection' extends this concept to include e-seroconversion with decreased serum viral load and biochemical remission. These events must be well-characterized before treatment outcomes can be evaluated. We examined the rates of e-seroconversion and achievement of inactive chronic infection among children with chronic HBV infection. Children who were HBsAg positive >6 months were identified retrospectively between 1983 and 2008 from the Hospital for Sick Children Liver Clinic. Inactive chronic infection was defined as loss of HBeAg, serum ALT ≤40 IU/mL, and HBV DNA <10(6 ) IU/mL. Both e-seroconversion and achievement of inactive chronic infection were characterized using survival analysis. The effect of transmission route, treatment, age at diagnosis, ethnicity, gender and baseline ALT on these rates was evaluated with univariate and multiple regression. Of 252 HBeAg-positive cases, 59.9% had HBV-infected mothers, 77% were Asian, and 33 received interferon-α. Untreated children were younger at last follow-up (mean 14.5 vs 17.6 years), had lower ALT (median 60 vs 116 IU/mL) and had shorter follow-up (6.6 vs 9.1 years, all P < 0.002) compared to treated children. Crude e-seroconversion rate was 41.7% over 0.5-19.1 years of follow-up, and this was not affected by transmission route (P = 0.93), gender (P = 0.62) nor treatment (P = 0.08). 49% achieved inactive chronic infection by age 19 years. Being non-Asian, age at diagnosis<3 years, and ALT ≥40 IU/mL were associated with a higher rate of e-seroconversion and achieving inactive chronic infection (P < 0.0001). Almost 50% of children achieved inactive chronic infection by early adulthood.

Evidence of interactions in Co-HfO2 granular films

Co-HfO(2) granular films with varying numbers of bilayers were studied by means of transmission electron microscopy (TEM), magnetization loops and zero-field-cooled and field-cooled (ZFC-FC) magnetization. Grain size properties inferred from the measurement techniques were found to be different from those observed from TEM. We show that a modified Langevin function that accounts for dipolar interactions reconciles grain size properties observed by TEM. The mean blocking temperature seen from ZFC-FC analysis was observed to be greater compared to that inferred from TEM data. Moreover, it exhibited a trend with increasing numbers of bilayers. We proposed an explanation for these differences on the basis of the degree of dipolar interactions.

PlasmaKinetic™ (bipolar) transurethral resection of prostate: a prospective trial to study pathological artefacts, surgical parameters and clinical outcomes

INTRODUCTION

The aims of the study were to compare the degree of cautery artefacts in prostatic chips between monopolar and PlasmaKinetic™ transurethral resection of prostate (TURP), and to determine if there is any difference in the intraoperative and post surgical parameters between them.

METHODS

After institutional review board approval, patients were prospectively enrolled to undergo PlasmaKinetic™ TURP. Their parameters were compared with those of the historical monopolar TURP controls. All histological specimens were reviewed by a single senior pathologist.

RESULTS

46 patients were recruited to undergo PlasmaKinetic™ TURP. The resection time was significantly longer for the bipolar group compared to the monopolar group (50.2 versus 36.7 min, p-value is 0.001). The speed of resection (resection weight/time) was lower for the bipolar group (0.45 versus 0.56 g/min, p-value is 0.017). More irrigant was used for the bipolar group (21.2 versus 15.6 litres, p-value is 0.001) intraoperatively. There was no statistically significant difference in terms of intraoperative drop in haemoglobin and serum sodium change between the two groups. There seems to be a lesser degree of cautery artefacts in the PlasmaKinetic™ group than the monopolar group (42.17 versus 45.07 microns); however, this was not statistically significant (p-value is 0.452).

CONCLUSION

Bipolar TURP seems to result in a lesser degree of cautery artefacts when compared to conventional monopolar TURP, albeit statistically insignificant, compared to monopolar TURP. TURP also resulted in a longer resection time and increased irrigant use, but no difference in blood loss and serum sodium levels.

Narrowing the Modeling Gap: A Cluster-Ranking Approach to Coreference Resolution

Traditional learning-based coreference resolvers operate by training the mention-pair model for determining whether two mentions are coreferent or not. Though conceptually simple and easy to understand, the mention-pair model is linguistically rather unappealing and lags far behind the heuristic-based coreference models proposed in the pre-statistical NLP era in terms of sophistication. Two independent lines of recent research have attempted to improve the mention-pair model, one by acquiring the mention-ranking model to rank preceding mentions for a given anaphor, and the other by training the entity-mention model to determine whether a preceding cluster is coreferent with a given mention. We propose a cluster-ranking approach to coreference resolution, which combines the strengths of the mention-ranking model and the entity-mention model, and is therefore theoretically more appealing than both of these models. In addition, we seek to improve cluster rankers via two extensions: (1) lexicalization and (2) incorporating knowledge of anaphoricity by jointly modeling anaphoricity determination and coreference resolution. Experimental results on the ACE data sets demonstrate the superior performance of cluster rankers to competing approaches as well as the effectiveness of our two extensions.

Glomerular filtration rate following pediatric liver transplantation--the SPLIT experience

Impaired kidney function is a well-recognized complication following liver transplantation (LT). Studies of this complication in children have been limited by small numbers and insensitive outcome measures. Our aim was to define the prevalence of, and identify risk factors for, post-LT kidney dysfunction in a multicenter pediatric cohort using measured glomerular filtration rate (mGFR). We conducted a cross-sectional study of 397 patients enrolled in the Studies in Pediatric Liver Transplantation (SPLIT) registry, using mGFR < 90 mL/min/1.73 m(2) as the primary outcome measure. Median age at LT was 2.2 years. Primary diagnoses were biliary atresia (44.6%), fulminant liver failure (9.8%), metabolic liver disease (16.4%), chronic cholestatic liver disease (13.1%), cryptogenic cirrhosis (4.3%) and other (11.8%). At a mean of 5.2 years post-LT, 17.6% of patients had a mGFR < 90 mL/min/1.73 m(2) . In univariate analysis, factors associated with this outcome were transplant center, age at LT, primary diagnosis, calculated GFR (cGFR) at LT and 12 months post-LT, primary immunosuppression, early post-LT kidney complications, age at mGFR, height and weight Z-scores at 12 months post-LT. In multivariate analysis, independent variables associated with a mGFR <90 mL/min/1.73 m(2) were primary immunosuppression, age at LT, cGFR at LT and height Z-score at 12 months post-LT.

Which Clustering Do You Want? Inducing Your Ideal Clustering with Minimal Feedback

While traditional research on text clustering has largely focused on grouping documents by topic, it is conceivable that a user may want to cluster documents along other dimensions, such as the author's mood, gender, age, or sentiment. Without knowing the user's intention, a clustering algorithm will only group documents along the most prominent dimension, which may not be the one the user desires. To address the problem of clustering documents along the user-desired dimension, previous work has focused on learning a similarity metric from data manually annotated with the user's intention or having a human construct a feature space in an interactive manner during the clustering process. With the goal of reducing reliance on human knowledge for fine-tuning the similarity function or selecting the relevant features required by these approaches, we propose a novel active clustering algorithm, which allows a user to easily select the dimension along which she wants to cluster the documents by inspecting only a small number of words. We demonstrate the viability of our algorithm on a variety of commonly-used sentiment datasets.

Exploring beyond viral load testing for EBV lymphoproliferation: role of serum IL-6 and IgE assays as adjunctive tests

We examined serum IL-6 and IgE assays as adjuncts to VL monitoring for PTLD. Paediatric solid organ transplant recipients were followed with VL monitoring. VL, IL-6, and IgE assays were compared between PTLD cases and non-cases at <3, 3-6 and >6 months after transplantation. Median IL-6 levels in PTLD cases were 15.5 (2.0-87.1) and 23.3 (2.1-276) pg/mL compared with 3.25 (0.92-114) and 3.5 (0.75-199.25) pg/mL in non-cases at 3-6 and >6 months, respectively (p = 0.006 and p = 0.005). At >6 months, IL-6 levels correlated with VL and PTLD occurrence (Spearman's coefficients = 0.40; p = 0.001 and 0.32; p = 0.003) in univariate analyses. No benefit was derived from performance of IgE levels. The sensitivity and specificity of high VL as a test of PTLD were 76.3% and 92.5%, while the negative predictive value and PPV of VL were 94.9% and 68.4%, respectively. Combining elevated IL-6 with high VL increased the PPV and specificity to 80% and 96.2%, respectively, and improved the receiver operating characteristic curve. Serum IL-6 levels can improve the clinician's ability to identify PTLD, among patients with elevated EBV viral loads.

Cause Identification from Aviation Safety Incident Reports via Weakly Supervised Semantic Lexicon Construction

The Aviation Safety Reporting System collects voluntarily submitted reports on aviation safety incidents to facilitate research work aiming to reduce such incidents. To effectively reduce these incidents, it is vital to accurately identify why these incidents occurred. More precisely, given a set of possible causes, or shaping factors, this task of cause identification involves identifying all and only those shaping factors that are responsible for the incidents described in a report. We investigate two approaches to cause identification. Both approaches exploit information provided by a semantic lexicon, which is automatically constructed via Thelen and Riloff's Basilisk framework augmented with our linguistic and algorithmic modifications. The first approach labels a report using a simple heuristic, which looks for the words and phrases acquired during the semantic lexicon learning process in the report. The second approach recasts cause identification as a text classification problem, employing supervised and transductive text classification algorithms to learn models from incident reports labeled with shaping factors and using the models to label unseen reports. Our experiments show that both the heuristic-based approach and the learning-based approach (when given sufficient training data) outperform the baseline system significantly.

Symptoms after mould exposure including Stachybotrys chartarum, and comparison with darkroom disease

BACKGROUND

Mould-attributed symptoms have included features which overlap with unexplained syndromes such as sick building syndrome.

OBJECTIVES

We describe questionnaire and chart review findings in patients following exposure to moulds which include Stachybotrys and compare responses with two control groups.

METHODS

Thirty-two patients presented with symptoms attributed to mould exposures. Exposure identification for 25 patients had reported S tachybotrys chartarum as well as other mould (Aspergillus, Penicillium), 88% at work. The remaining seven had professionally visualized or self-reported/photographic exposure evidence only. A chart review was performed and a follow-up with a questionnaire, including questions on current health status, and nonspecific symptoms.

RESULTS

Cough, shortness of breath and chest tightness (at presentation) were reported in 79%, 70% and 64%, respectively, and persisted >6 weeks in 91%. Skin test(s) were positive to fungal extract(s) in 30%. Seventeen returned questionnaires were obtained 3.1 (SD 0.5) years after the initial clinic assessment. Among this subgroup, persisting asthma-like symptoms and symptoms suggestive of sick building syndrome were frequent, and similar to a group previously assessed for darkroom disease among medical radiation technologists. The mould-exposed group more commonly reported they were bothered when walking in a room with carpets, complained of a chemical or metallic taste in their mouth, and had problems in concentration when compared with a control physiotherapist group (P < 0.005).

CONCLUSIONS

Although only a minority with health concerns from indoor mould exposure had demonstrable mould-allergy, a significant proportion had asthma-like symptoms. Other symptoms were also common and persistent after the initial implicated exposure.

An association between floor vacuuming and dust-mite and serum eosinophil cationic protein in young asthmatics

Although vacuum cleaning is recommended to reduce allergen levels and improve asthma and allergic rhinitis symptoms, some studies suggest it may increase allergen load in homes. We conducted a cross-sectional study to determine if home floor vacuuming was associated with sensitization to dust-mites and cockroaches, and serum eosinophil cationic protein (ECP), a biomarker for atopy, in 102 physician-diagnosed spirometry-confirmed asthmatics. We collected data on floor type, floor cleaning method and frequency, asthma severity, allergy medications used, serum ECP and skin prick tests (SPT) to three dust-mites [Dermatophagoides pteronyssisinus (Der p), Dermatophagoides farinae (Der f) and Blomia tropicalis (Blo t)] and two cockroaches [Periplanata americana (Per a) and Blatella germanica (Bla g)]. Those who vacuumed had increased sensitization to three dust-mites [adjusted ORs (95%CI) = Der p: 26.6 (1.8-405.2); Der f: 44.8 (3.2-620.9); Blo t: 14.1 (1.8-108.1)] but not to cockroaches, adjusted for cleaning frequency and other methods of floor cleaning. Subjects who vacuumed their floor had higher levels of serum ECP than those who did not [adjusted median difference (95%CI): 9.4 (1.1-17.7)], adjusted for use of nasal corticosteroids among those with allergic rhinitis. Vacuuming is associated with increased sensitization to dust-mite allergens and higher serum ECP.

PRACTICAL IMPLICATIONS

We found an association between floor vacuuming and increased sensitization to dust-mite allergens and higher levels of an atopy biomarker. Current recommendations to use vacuuming to control allergen exposure and allergic conditions may need to be reconsidered until further studies are performed.