Elemental formula associated hypophosphataemic rickets.

OBJECTIVES: Hypophosphataemic rickets (HR) is usually secondary to renal phosphate wasting but may occur secondary to reduced intake or absorption of phosphate. We describe a series of cases of HR associated with the use of Neocate®, an amino-acid based formula (AAF). METHODS: A retrospective review of cases with HR associated with AAF use presenting to centres across the United Kingdom. RESULTS: 10 cases were identified, over a 9 month period, all associated with Neocate® use. The age at presentation was 5 months to 3 years. The majority (8/10) were born prematurely. Gastro oesophageal reflux disease (6/10) was the most frequent indication for AAF use. Radiologically apparent rickets was observed after a median of 8 months (range 3-15 months) of exclusive Neocate® feed. The majority (7/10) were diagnosed on the basis of incidental findings on radiographs: rickets (6/10) or fracture with osteopenia (5/10). All patients had typical biochemical features of HR with low serum phosphate, high alkaline phosphatase, normal serum calcium and 25 hydroxyvitamin D. However, in all cases the tubular reabsorption of phosphate (TRP) was ≥96%. Phosphate supplementation resulted in normalisation of serum phosphate within 1-16 weeks, and levels remained normal only after Neocate® cessation. In patients with sufficient follow up duration (4/10), normalisation of phosphate and radiological healing of rickets was noted after 6 months (range: 6-8 months) following discontinuation of Neocate®. CONCLUSION: The presence of a normal TRP and resolution of hypophosphataemia and rickets following discontinuation of Neocate® indicates this is a reversible cause likely mediated by poor phosphate absorption. Close biochemical surveillance is recommended for children on Neocate®, especially in those with gastrointestinal co-morbidities, with consideration of a change in feed or phosphate supplementation in affected children.

Georeferenced soil provenancing with digital signatures.

The provenance or origin of a soil sample is of interest in soil forensics, archaeology, and biosecurity. In all of these fields, highly specialized and often expensive analysis is usually combined with expert interpretation to estimate sample origin. In this proof of concept study we apply rapid and non-destructive spectral analysis to the question of direct soil provenancing. This approach is based on one of the underlying tenets of soil science - that soil pedogenesis is spatially unique, and thus digital spectral signatures of soil can be related directly, rather than via individual soil properties, to a georeferenced location. We examine three different multivariate regression techniques to predict GPS coordinates in two nested datasets. With a minimum of data processing, we show that in most instances Eastings and Northings can be predicted to within 20% of the range of each within the dataset using the spectral signatures produced via portable x-ray fluorescence. We also generate 50 and 95% confidence intervals of prediction and express these as a range of GPS coordinates. This approach has promise for future application in soil and environmental provenancing.

The potential for portable X-ray fluorescence determination of soil copper at ancient metallurgy sites, and considerations beyond measurements of total concentrations.

Copper (Cu) at ancient metallurgy sites represents the earliest instance of anthropogenically generated metal pollution. Such sites are spread across a wide range of environments from Eurasia to South America, and provide a unique opportunity to investigate the past and present extent and impact of metalworking contamination. Establishing the concentration and extent of soil Cu at archaeometallurgy sites can enhance archaeological interpretations of site use but can also, more fundamentally, provide an initial indication of contamination risk from such sites. Systematic evaluations of total soil Cu concentrations at ancient metalworking sites have not been conducted, due in part to the limitations of conventional laboratory-based protocols. In this paper, we first review what is known about Cu soil concentrations at ancient metallurgy sites. We then assess the benefits and challenges of portable X-ray fluorescence spectrometry (pXRF) as an alternative, rapid technique for the assessment of background and contaminant levels of Cu in soils. We conclude that pXRF is an effective tool for identifying potential contamination. Finally, we provide an overview of some major considerations beyond total Cu concentrations, such as bioavailability assessments, that will need to be considered at such sites to move toward a complete assessment of environmental and human risk.

Physical soil architectural traits are functionally linked to carbon decomposition and bacterial diversity.

Aggregates play a key role in protecting soil organic carbon (SOC) from microbial decomposition. The objectives of this study were to investigate the influence of pore geometry on the organic carbon decomposition rate and bacterial diversity in both macro- (250-2000 µm) and micro-aggregates (53-250 µm) using field samples. Four sites of contrasting land use on Alfisols (i.e. native pasture, crop/pasture rotation, woodland) were investigated. 3D Pore geometry of the micro-aggregates and macro-aggregates were examined by X-ray computed tomography (µCT). The occluded particulate organic carbon (oPOC) of aggregates was measured by size and density fractionation methods. Micro-aggregates had 54% less µCT observed porosity but 64% more oPOC compared with macro-aggregates. In addition, the pore connectivity in micro-aggregates was lower than macro-aggregates. Despite both lower µCT observed porosity and pore connectivity in micro-aggregates, the organic carbon decomposition rate constant (Ksoc) was similar in both aggregate size ranges. Structural equation modelling showed a strong positive relationship of the concentration of oPOC with bacterial diversity in aggregates. We use these findings to propose a conceptual model that illustrates the dynamic links between substrate, bacterial diversity, and pore geometry that suggests a structural explanation for differences in bacterial diversity across aggregate sizes.

Febrile neutropenia and refeeding syndrome.

We describe the management of a 4-year-old child with acute lymphoblastic leukaemia (ALL) who presented with febrile neutropenia, Cryptosporidium and subsequently developed refeeding syndrome. Febrile neutropenia is common and can be life-threatening and we highlight the identification of well low-risk neutropenic children with resolved febrile illnesses suitable for early discharge. We also discuss the potential management strategies for Cryptosporidium Refeeding syndrome is not common, but should be considered as a cause of acute inpatient deterioration and is a significant risk, with potential morbidity, in children who have undergone a period of catabolism. This article reviews the current literature and provides useful guidance on these issues.

Practical management of functional abdominal pain in children.

Functional abdominal pain (FAP) is common in childhood, but is not often caused by disease. It is often the impact of the pain rather than the pain itself that results in referral to the clinician. In this review, we will summarise the currently available evidence and discuss the functional dimensions of the presentation, within the framework of commonly expressed parental questions. Using the Rome III criteria, we discuss how to classify the functional symptoms, investigate appropriately, provide reassurance regarding parental worries of chronic disease. We outline how to explain the functional symptoms to parents and an individualised strategy to help restore function.

Developing best-practice Bayesian Belief Networks in ecological risk assessments for freshwater and estuarine ecosystems: a quantitative review.

Bayesian Belief Networks (BBNs) are being increasingly used to develop a range of predictive models and risk assessments for ecological systems. Ecological BBNs can be applied to complex catchment and water quality issues, integrating multiple spatial and temporal variables within social, economic and environmental decision making processes. This paper reviews the essential components required for ecologists to design a best-practice predictive BBN in an ecological risk assessment (ERA) framework for aquatic ecosystems, outlining: (1) how to create a BBN for an aquatic ERA?; (2) what are the challenges for aquatic ecologists in adopting the best-practice applications of BBNs to ERAs?; and (3) how can BBNs in ERAs influence the science/management interface into the future? The aims of this paper are achieved using three approaches. The first is to demonstrate the best-practice development of BBNs in aquatic sciences using a simple nutrient model. The second is to discuss the limitations and challenges aquatic ecologists encounter when applying BBNs to ERAs. The third is to provide a framework for integrating best-practice BBNs into ERAs and the management of aquatic ecosystems. A quantitative review of the application and development of BBNs in aquatic science from 2002 to 2014 was conducted to identify areas where continued best-practice development is required. We outline a best-practice framework for the integration of BBNs into ERAs and study of complex aquatic systems.

Lymphotoxin beta receptor signaling limits mucosal damage through driving IL-23 production by epithelial cells.

The immune mechanisms regulating epithelial cell repair after injury remain poorly defined. We demonstrate here that lymphotoxin beta receptor (LTßR) signaling in intestinal epithelial cells promotes self-repair after mucosal damage. Using a conditional gene-targeted approach, we demonstrate that LTßR signaling in intestinal epithelial cells is essential for epithelial interleukin-23 (IL-23) production and protection against epithelial injury. We further show that epithelial-derived IL-23 promotes mucosal wound healing by inducing the IL-22-mediated proliferation and survival of epithelial cells and mucus production. Additionally, we identified CD4(-)CCR6(+)T-bet(-) RAR-related orphan receptor gamma t (RORγt)(+) lymphoid tissue inducer cells as the main producers of protective IL-22 after epithelial damage. Thus, our results reveal a novel role for LTßR signaling in epithelial cells in the regulation of intestinal epithelial cell homeostasis to limit mucosal damage.

Risk factors for sporadic domestically acquired Salmonella serovar Enteritidis infections: a case-control study in Ontario, Canada, 2011.

In Ontario, Canada, the number of Salmonella Enteritidis (SE) cases increased over the years 2005-2010. A population-based case-control study was undertaken from January to August 2011 for the purpose of identifying risk factors for acquiring illness due to SE within Ontario. A total of 199 cases and 241 controls were enrolled. After adjustment for confounders, consuming any poultry meat [adjusted odds ratio (aOR) 2·24, 95% confidence interval (CI) 1·31-3·83], processed chicken (aOR 3·32, 95% CI 1·26-8·76) and not washing hands following handling of raw eggs (OR 2·82, 95% CI 1·48-5·37) were significantly associated with SE infection. The population attributable fraction was 46% for any poultry meat consumption and 10% for processed chicken. Poultry meat continues to be identified as a risk factor for SE illness. Control of SE at source, as well as proper food handling practices, are required to reduce the number of SE cases.

Progression of coronary artery calcification in asymptomatic individuals with pre-existing calcium score.

AIM: Coronary artery calcification (CAC) has been introduced as a reliable, non-invasive marker of atherosclerosis. In this retrospective study, we investigated the progression of CAC using electron beam computed tomography. METHODS: The study enrolled 598 individuals (521 males; mean age: 59.3±8.3 years) with initial CAC score (CACS) ≥10. The mean interscan period was 2.4±1.35 years (range: 1-7 years). The mean CACS, for the entire cohort, was 262.4±423.9 at baseline scan and 380.3±547.6 at follow-up. The mean annualized progression in CACS was 57.7±123.7; 47.4±66.5 in females and 58.3±128.1 in males (P=0.46). The mean annualized progression in CACS was 39.6±61.3 in individuals <60 years and 75.7±161.5 in individuals >60 years (P=0.0003). In multivariate analysis, only baseline CACS (P<0.0001) and smoking (P=0.002) were independently associated with the annual change in CACS.

Building HIA approaches into strategies for green space use: an example from Plymouth's (UK) Stepping Stones to Nature project.

The health and well-being benefits of access to green space are well documented. Research suggests positive findings regardless of social group, however barriers exist that limit access to green space, including proximity, geography and differing social conditions. Current public health policy aims to broaden the range of environmental public health interventions through effective partnership working, providing opportunities to work across agencies to promote the use of green space. Health Impact Assessment (HIA) is a combination of methods and procedures to assess the potential health and well-being impacts of policies, developments and projects. It provides a means by which negative impacts can be mitigated and positive impacts can be enhanced, and has potential application for assessing green space use. This paper describes the application of a HIA approach to a multi-agency project (Stepping Stones to Nature--SS2N) in the UK designed to improve local green spaces and facilitate green space use in areas classified as having high levels of deprivation. The findings suggest that the SS2N project had the potential to provide significant positive benefits in the areas of physical activity, mental and social well-being. Specific findings for one locality identified a range of actions that could be taken to enhance benefits, and mitigate negative factors such as anti-social behaviour. The HIA approach proved to be a valuable process through which impacts of a community development/public health project could be enhanced and negative impacts prevented at an early stage; it illustrates how a HIA approach could enhance multi-agency working to promote health and well-being in communities.

Coronary artery calcification progression in asymptomatic individuals with initial score of zero.

The aim of this study is to determine the progression of coronary artery calcification (CAC) using electron beam computed tomography (CT) when the initial CAC score (CACS) is zero and to determine the best interval to repeat a CAC scan. We studied 388 individuals with zero CACS (308 males; mean age: 48.8 ± 8.26 years) who underwent 2 consecutive CT scans in a period of at least 12 months apart. The interscan period was 2.99 ± 1.35 years (range: 1-6 years). Three-quarters of the individuals (75%) did not develop any CAC progression, 20.87% presented CAC progression of 1 to 10, 3.6% had 11 to 50, whereas only 0.51% had >50. The average time of new CAC development was 4.2 ± 1.1 years. Individuals with CAC progression presented higher incidence of hypertension, diabetes mellitus, hypercholesterolaemia and higer frequency of male gender than those with without CAC changes (p<0.02). No cardiac events occurred during the follow-up period.

Differences in clinical profile of individuals with severe and markedly elevated coronary artery calcification detected by electron beam computed tomography.

Although several studies have demonstrated the association between coronary artery calcification (CAC) and coronary artery disease events, the underlying mechanism has not been fully elucidated. Furthermore, extensive CAC still remains a poorly understood phenomenon. The objective of this study is to determine the clinical characteristics and differences between 831 asymptomatic individuals with very high CAC scores (CACS ≥ 1000) and 497 asymptomatic individuals with CAC scores of 400 to 999. Individuals with CACS ≥ 1000 were more likely to have hypertension ([HTN]; P = .0004), hypercholesterolemia (P = .0001), diabetes mellitus ([DM] P = .005), and high body mass index ([BMI]; P = .03) compared with individuals with CACS = 400-999. On multivariable analysis, age (P < .0001) and BMI (P = .01) were found to be significant risk factors for the presence of very high CAC. While for males, age (P < .0001), hypercholesterolemia (P = .001), DM (P = .002), and obesity (P = .003) were independent risk factors; in females only HTN (P = .04) was independent risk factor.

Coping, meaning and symptom experience: a narrative approach to the overwhelming impacts of breast cancer in the first year following diagnosis.

PURPOSE: Women's experience of breast cancer treatment is a complex feature of survival which reflects and impacts upon the quality of their inter-personal relationships. We aimed to explore and present the issues and means through which these women relate their symptoms, treatments and effects. We utilised the 'cancer journey' as a heuristic device to chart women's experiences in the first year following diagnosis. METHOD: Thirty-nine interviews were conducted over one year with a convenience sample of 10 women newly diagnosed with breast cancer recruited from a specialist oncology centre in England in 2005. Transcriptions of the interviews were analysed using a thematic narrative approach. RESULTS: The findings suggested how women related coping and meaning to their experience of relationships, return to work, and self-management of breast cancer symptoms. The overwhelming impact of breast cancer was personal to each sufferer and yet reflects commonly reported treatment effects. These included unmet need for fatigue management, the impact of adaptation to hair loss and disfigurement, and the evident need for sexual health and relationship counselling. CONCLUSION: The multi-dimensional aspects of womens' relationships with family, friends, co-workers and care professionals impacts significantly on their coping strategies and how they make sense of their breast cancer experiences, which consequently bears upon symptom experience, and experience of survival. We suggest that narrative representation bears witness to the common and differing experiences of how women newly diagnosed with breast cancer cope with symptom experience and survival over time. Narrative representation of breast cancer is a useful pedagogical resource for supportive cancer care and highlights the needs of women that need to be addressed by health care professionals.

Management of obstetric anal sphincter injuries--a role for the colorectal surgeon.

AIM: To determine if surgical repair of third and fourth degree obstetric perineal tears by an experienced colorectal surgeon produces satisfactory functional results in the short and long term. METHOD: Consecutive deliveries were studied prospectively over a 32-month period. All patients with suspected third or fourth degree tears were referred to the colorectal team. Following confirmation of the injury, patients underwent surgical repair using a standard overlapped technique according to an established protocol. The patients were reviewed 2 months later. Long-term continence was determined, by postal and telephone follow up, after a minimum of 3 years. RESULTS: Fifty-nine sphincter injuries were identified and repaired by the colorectal team. Two months following repair 51 (86%) of patients had normal continence, four (7%) had urgency, and five (8%) had occasional incontinence of flatus. All patients with any degree of incontinence underwent endoanal ultrasound at which no sphincter defects were noted, and all improved symptomatically following pelvic floor physiotherapy. Long-term follow up data was obtained in 45 women. Thirty-nine (87%) had normal continence scores, 11 (24%) described urgency, but only three (7%) were often incontinent of liquid stool. Seven (15%) were occasionally incontinent of flatus. CONCLUSION: Excellent short and long-term functional results were obtained in the repair of third and fourth degree tears when performed by experienced colorectal surgeons. Since the protocol was established, obstetricians in North Cheshire have adopted the double overlapped technique, and now manage the majority of these injuries themselves.