Implementation of a fetal ultrasound telemedicine service: women's views and family costs.

BACKGROUND: The complexity of fetal medicine (FM) referrals that can be managed within obstetric units is dependent on the availability of specialist ultrasound expertise. Telemedicine can effectively transfer real-time ultrasound images via video-conferencing. We report the successful introduction of a fetal ultrasound telemedicine service linking a specialist fetal medicine (FM) centre and a remote obstetric unit. METHODS: Over a four-year period from October 2015, all women referred for FM consultation from the obstetric unit were seen via telemedicine, excluding cases where invasive testing, intrauterine therapy or cardiac anomalies were anticipated. The outcomes measured included the indication for FM referral; scan duration and image and sound quality during the consultation. Women's perceptions of the telemedicine consultation and estimated costs to attend the FM centre were measured by a structured questionnaire completed following the first telemedicine appointment during the Phase 1 of the project. RESULTS: Overall, 297 women had a telemedicine consultation during Phase 1 (pilot and evaluation) and Phase 2 (embedding and adoption) of the project, which covered a 4 year period 34 women completed questionnaires during the Phase 1 of the study. Travel to the telemedicine consultation took a median (range) time of 20 min (4150), in comparison to an estimated journey of 230 min (120,450) to the FM centre. On average, women would have spent approximately £28 to travel to the FM centre per visit. The overall costs for the woman and her partner/ friend to attend the FM centre was estimated to be £439. Women were generally satisfied with the service and valued the opportunity to have a FM consultation locally. CONCLUSIONS: We have demonstrated that a fetal ultrasound telemedicine service can be successfully introduced to provide FM ultrasound of sufficient quality to allow fetal diagnosis and specialist consultation with parents. Furthermore, the service is acceptable to parents, has shown a reduction in family costs and journey times.

A comparative synthesis of transcriptomic analyses reveals major differences between WSSV-susceptible Litopenaeus vannamei and WSSV-refractory Macrobrachium rosenbergii.

Since the 1990s White Spot Syndrome Virus (WSSV) has severely affected shrimp aquaculture worldwide causing a global pandemic of White Spot Disease (WSD) in penaeid culture. However, not all decapod species that can be infected by WSSV show the same susceptibility to the virus, thus raising interesting questions regarding the potential genetic traits that might confer resistance to WSSV. In order to shed light into the genetic markers of WSSV resistance, we employed a dual approach: i) we initially analysed the transcriptomes derived from the hepatopancreas of two species, the susceptible white shrimp Litopenaeus vannamei and the refractory fresh water prawn Macrobrachium rosenbergii, both infected with WSSV. We found a large number of differentially expressed genes (DEGs) belonging to the immune system (mostly anti-microbial peptides and haemolymph clotting components) that were generally up-regulated in M. rosenbergii and down-regulated in L. vannamei. Further, in both species we identified many up-regulated DEGs that were related to metabolism (suggesting a metabolic shift during the infection) and, interestingly, in L. vannamei only, we found several DEGs that were related to moult and suggested an inhibition of the moult cycle in this species following WSSV infection. ii) we then identified a limited number of genetic markers putatively linked with WSD tolerance by employing an ecological genomics approach in which we compared published reports with our own RNA-seq datasets for different decapod species infected with WSSV. Using this second comparative approach, we found nine candidate genes which are consistently down-regulated in susceptible species and up-regulated in refractory species and which have a role in immune response. Together our data offer novel insights into gene expression differences that can be found in susceptible and refractory decapod species infected with WSSV and provide a valuable resource towards our understanding of the potential genetic basis of tolerance to WSSV.

Identification of possible determinants of inpatient mortality using Classification and Regression Tree (CART) analysis in hospitalized oldest old patients.

Current demographic trends suggest that there will be increasing numbers of older people in the future. Relatively little information is available regarding factors which influence mortality in the acutely unwell oldest old. This study uses the CART technique on data relating to the oldest old, to identify potential predictors of inpatient mortality in patients over 90 years old admitted acutely to the hospital due to various medical emergencies in two UK centers. The sample included 393 patients aged 90 years and older, with 67.5% females and 32.5% males and a mean age of 91.1 years. We aimed to generate hypotheses in order to identify potential acute illness prognostic indicators of inpatient mortality in this age group. The factors identified in this analysis which were associated with inpatient mortality in this patient population were raised serum urea concentration (>13.95 mmol/L), low oxygen saturation levels (<94%), hyponatremia (<128 mmol/L), and raised white cell count (>17 × 10(9)/L). The predictability of using these cut off points in inpatient as well as early in-hospital death should be validated in future studies.

Changes in immune gene expression and resistance to bacterial infection in lobster (Homarus gammarus) post-larval stage VI following acute or chronic exposure to immune stimulating compounds.

Real-time PCR was used to measure changes in transcript abundance of genes encoding important immune proteins, namely prophenoloxidase (proPO gene), beta-1,3-glucan binding protein (betaGBP gene) and a 12.2 kDa antimicrobial peptide (amp gene) in post-larval stage VI (PLVI) juveniles of the European lobster, Homarus gammarus. Gene expression was studied in both healthy PLVI and following single or repeat exposure to a range of compounds claimed to induce immune reactivity. A single acute (3-h) exposure to any of the tested stimulants did not produce a significant increase in expression of either the proPO or betaGBP genes, measured 6h after stimulation. However, there were a small sub-group of positive responders, identified mainly from betaGBP expression, within the experimental groups stimulated with either a beta-1,3-glucan or an alginate. There was also no significant increase in the expression of any of the three genes tested 24 h after repeated weekly (3-h) exposures to a either the beta-1,3-glucan or the alginate over the longer (36-day) period. The results do show that amp is expressed at an extremely high level compared to proPO or betaGBP in healthy animals and a significant correlation was found between the expression of proPO and both betaGBP and amp, irrespective of whether or not the larvae were stimulated. None of the immune stimulated compounds improved survival of PLVI challenged with the opportunistic pathogen, Listonella anguillarum, or the lobster pathogen, Aerococcus viridans var. homari. Thus, we found no evidence to support recent claims that immunity and disease resistance can be primed or promoted within a given population of crustaceans or that these animals exhibit functional immune memory to some soluble immune elicitors.

Cloning of a crustin-like, single whey-acidic-domain, antibacterial peptide from the haemocytes of the European lobster, Homarus gammarus, and its response to infection with bacteria.

Degenerate PCR was used to isolate a 221-base pair nucleotide sequence of a new crustin-like antibacterial peptide from the haemocytes of the European lobster, Homarus gammarus. Rapid amplification of cDNA ends was used to extend the sequence to determine the complete open reading frame and un-translated regions. The inferred amino acid sequence of this peptide was found to be similar to crustin-like peptides isolated for several species of shrimp as well as the shore crab, Carcinus maenas. The sequence also contains a single-whey-acidic protein (WAP) domain, similar to novel antibacterial single-whey-acidic domain (SWD) peptides that have been recently described in the tiger shrimp, Penaeus monodon, and the Pacific white shrimp, Litopenaeus vannamei. Real-time PCR was used to analyse the expression of the gene coding for this peptide. The gene is up regulated after inoculation with the Gram-positive lobster pathogen Aerococcus viridans var. homari but down regulated after inoculation with the Gram-negative bacteria Listonella anguillarum. Phylogenetic analysis of this new peptide shows that it is most related to other antimicrobial crustin peptides and that the crustins are only distantly related to the antibacterial SWD peptides recently described.

Cloning of a glycosylphosphatidylinositol-anchored alpha-2-macroglobulin cDNA from the ascidian, Ciona intestinalis, and its possible role in immunity.

Molecular approaches were used to study thiolester-containing genes in the ascidian, Ciona intestinalis. RT-PCR, RACE and genome mining revealed that this animal expresses not only conventional alpha-2-macroglobulin (alpha2m) and two forms of C3 but also a gene encoding a glycosylphosphatidylinositol (GPI)-anchored alpha2m. Previously, GPI-anchored alpha2ms have been reported only for humans and mice. We propose that GPI-anchored alpha2ms constitute a third subgroup of the alpha2m superfamily and may represent an important evolutionary stage in the phylogeny of the thiolester containing proteins. Its occurrence in an ascidian shows its origin pre-dates the evolution of the vertebrates. In C. intestinalis this GPI-anchored alpha2m, designated Ciona alpha2m-GPI, is expressed in the hepatopancreas, circulating coelomic blood cells and the gut of adults. It is also expressed in 3-5 days old larvae. Its tissue distribution coupled with its sequence characteristics and unusual domain structure indicate that the encoded protein probably assists in host defence by entrapping and inhibiting proteases from micro-organisms.

Two novel muramidases from skin mucosa of rainbow trout (Oncorhynchus mykiss).

Two novel antibacterial muramidases were purified to homogeneity from skin exudates of rainbow trout (Oncorhynchus mykiss). Unusually, one has an acidic isoelectric point and it is the first anionic muramidase to be reported for fish. Its molecular mass is 14,268 Da, as determined by mass spectrometry. The other muramidase is cationic with a mass of 14,252 Da. Partial N-terminal amino acid sequencing and peptide mapping strongly point to it being a c-type lysozyme, the first to be purified and characterised from skin of a salmonid. Its optimum pH ranges from 4.5 to 5.5 and its optimum temperature, at pH 5.0, is 33-49 degrees C, although it still exhibits activity at 5 degrees C. It is strongly bactericidal to the Gram-(+) bacterium Planococcus citreus, with a minimum bactericidal concentration of 100 U ml(-1), but is neither chitinolytic nor haemolytic. These two muramidases probably contribute to epithelial defence of the fish against microbes, either alone or in synergism with antibacterial peptides.

A pilot study of motivational interviewing in adolescents with diabetes.

AIMS: To obtain preliminary data on the impact of motivational interviewing, a counselling approach to behaviour change, on glycaemic control, wellbeing, and self-care of adolescents with diabetes. METHODS: Twenty two patients aged 14-18 years participated in motivational interviewing sessions during a six month intervention. The effects of the intervention on HbA1c and a range of psychological factors were assessed. RESULTS: Mean HbA1c decreased from 10.8% to 9.7% during the study and remained significantly lower after the end of the study. Fear of hypoglycaemia was reduced and diabetes was perceived as easier to live with. There were no other significant changes in the psychological measures. By contrast no reduction in HbA1c values was observed in a comparison group who did not receive the motivational interviewing intervention. CONCLUSION: The findings of this pilot study indicate that motivational interviewing may be a useful intervention in helping adolescents improve their glycaemic control. A larger, longer term randomised controlled study is indicated to clarify the mechanisms and extent of these benefits.

Lipopolysaccharide induces DNA-synthesis in a sub-population of hemocytes from the swimming crab, Liocarcinus depurator.

The swimming crab, Liocarinus depurator, contains a small proportion of circulating blood cells which enter S-phase in vitro, as revealed by BrdU assay. These cells are enriched within the semigranular cell band produced by density gradient centrifugation on Percoll and their proportion is significantly higher in blood samples taken from crabs injected 3h previously with lipopolysaccharide (LPS). The occurrence of these cells does not persist as blood samples taken 12h post-injection show similar numbers of these cells to those from saline-treated and untreated controls. However, their appearance appears to be dose related; hemolymph from animals given 15 microg LPS per animal contains greater numbers than that from animals given LPS doses of 0.15 or 0.015 microg per animal. Estimation of the probable number of these cells per ml of the hemolymph, taking into account cell viability and changes in the size of the semigranular cell pool, indicates that they are very rare, comprising merely ca 0.06% of the total cell count. Notwithstanding, this still represents a baseline population in the region of 1.25 x 10(4) ml-1. More importantly, their number rises, approximately 11-fold to ca 14 x 10(4) ml-1 of hemolymph by 3h of injection of LPS. These results show that certain hemocytes from a brachyuran crab can synthesise DNA in vitro, and offers evidence that these cells constitute a rare but distinct sub-population of hemocytes that co-migrate with the semigranular cells during density gradient centrifugation. Since the cells received the stimulus to enter S-phase in vivo, the response must represent one of the mechanisms used by decapods to restore the hemocyte number in the circulation after non-self challenge.

Heavy metals affect the circulating haemocyte number in the shrimp Palaemon elegans.

Environmental contamination by heavy metals produced by either anthropogenic or natural activities represents a threat to many species of aquatic animals worldwide. This study investigates the effect of short-term (96 h) exposure to dissolved heavy metals on the number of circulating haemocytes in the shrimp, Palaemon elegans (Rathke). Changes in haemocyte counts were determined in relation to time of exposure and with heavy metal concentration, relating the results to toxicity. It was found that immersion in artificial seawater containing Hg, Cd, Cu, Cr, Zn or Pb caused a decrease in the haemocyte count during the first 8 h exposure, although the haemocyte number returned to the initial (time 0) levels over the following 16 h immersion. In each case, the decrease in circulating haemocyte count induced by these metals was significantly different from the controls. The greatest decrease in haemocyte numbers (haemocytopenia) was induced by Pb, followed, in descending order, by Zn, Hg, Cr, Cu and Cd. The lethal level of haemocytopenia for the shrimps, defined as the number of haemocytes ml remaining in moribund animals (i.e. threshold of mortality) was found to be significantly lower than the levels tolerated by surviving shrimps (i.e. the limit of survival). The percentage of haemocytes remaining in the circulation at the threshold of mortality as a function of the number at time 0 was 56.6 +/- 8.8%. By contrast, the equivalent value for the threshold of survival was 63.7 +/- 12.4%. Importantly, the percentage decrease in haemocyte counts tolerated by P. elegans appears to vary with the metal. Animals treated with Pb or Zn survived with a lower number of circulating haemocytes than animals exposed to the other heavy metals.

Data mining for indicators of early mortality in a database of clinical records.

This paper describes the analysis of a database of diabetic patients' clinical records and death certificates. The objective of the study was to find rules that describe associations between observations made of patients at their first visit to the hospital and early mortality.Pre-processing was carried out and a knowledge discovery in databases (KDD) package, developed by the Lanner Group and the University of East Anglia, was used for rule induction using simulated annealing.The most significant discovered rules describe an association that was not generally known or accepted by the medical community, however, recent independent studies confirm their validity.

Spatial variability in the degradation rate of isoproturon in soil.

Thirty samples of soil were taken at 50-m intersections on a grid pattern over an area of 250 x 200 m within a single field with nominally uniform soil characteristics. Incubations of isoproturon (3-(4-isopropylphenyl)-1,1-dimethylurea) under standard conditions (15 degrees C; -33 kPa soil water potential) indicated considerable variation in degradation rate of the herbicide, with the time to 50% loss (DT50) varying from 6.5 to 30 days. The kinetics of degradation also varied between the sub-samples of soil. In many of them, there was an exponential decline in isoproturon residues; in others, exponential loss was followed by more rapid rates of decline; in a few soil samples, rapid rates of loss began shortly after the start of the incubations. In more detailed studies with soils from a smaller number of sub-sites (20), measurements were again made of isoproturon degradation rate, and the soils were analysed for organic matter content, pH, and nutrient status (N, P, K). Measurements were also made of isoproturon adsorption by the soils and of soil microbial biomass. Patterns of microbial metabolism were assessed using 95 substrates in Biolog GN plates. Soils showing rapid biodegradation were generally of higher pH and contained more available potassium than those showing slower degradation rates. They also had a larger microbial biomass and greater microbial metabolic diversity as determined by substrate utilisation on Biolog GN plates. The implications of the results for the efficacy and environmental behaviour of isoproturon are discussed.

Antibacterial proteins in rainbow trout, Oncorhynchus mykiss.

Antibacterial proteins are an important part of the innate immune system for all animals. They have been extensively studied in mammals, amphibians and invertebrates, but have received only scant attention in fish. Their expression and processing, however, provide a way of monitoring defence vigour during development or with seasonal changes in physiology. The aim of the present work was to identify and characterise antibacterial proteins in rainbow trout. In vitro analyses of extracts of the peripheral blood leucocytes, head kidney leucocytes and mucus from adult unstimulated (non-immune) fish showed marked antibacterial activity against Gram positive bacteria. Fractionation by ion exchange chromatography and RP-HPLC of head kidney extracts showed the presence of two forms of lysozyme but no constitutively expressed antimicrobial proteins of < 10 kDa. By contrast, chromatographic analyses of mucus revealed at least four antibacterial proteins. Two are conventional lysozymes, a third is an unusual lysozyme-like protein with a low isoelectric point, and the fourth is a highly hydrophobic, cationic peptide of c. 3 kDa.

Purification and characterization of a cysteine-rich 11.5-kDa antibacterial protein from the granular haemocytes of the shore crab, Carcinus maenas.

Extracts of the granular haemocytes of Carcinus maenas were subjected to ion-exchange chromatography and reverse-phase (RP)-HPLC to investigate the presence of an antibacterial protein of approximately 11 kDa. This protein was isolated, characterized and subjected to partial amino acid sequence analysis. It was found by mass spectrometry to have a molecular mass of 11 534 Da, to be cationic and hydrophobic and active only against marine Gram-positive bacteria. In addition its activity is stable after heating to 100 degrees C and is retained at concentrations as low as 10 microgram.mL-1. It has an unusual amino acid sequence, unlike any known antibacterial peptide described in the literature but bears a consensus disulphide domain signature, indicating that it might be a member of the four-disulphide core proteins. Partial cDNA sequence data has been obtained.

Construction of a gene probe for detection of P virus (Reoviridae) in a marine decapod.

The construction is described of a molecular probe to P virus, a double stranded RNA virus belonging to the Reoviridiae, which is an endemic pathogen of swimming crabs in British coastal waters and the Mediterranean. The probe hybridises to the P virus genome and can be easily produced in large quantities by PCR. It may be used by dot blotting or in situ hybridisation to specifically detect P virus in tissues and cells of natural or experimentally infected animals. Analyses of tissue samples with this probe show that the virus infects connective tissues of gills and hepatopancreas. This is the first gene probe to be constructed for a native viral pathogen of temperate water brachyurans and it will be useful to study virus ecology and virus-host interactions in vivo and in vitro. An understanding of these processes is essential to control and manage disease and, ultimately, to identify immune effectors capable of destroying viral pathogens.

Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence.

OBJECTIVE: To determine the incidence of surgically managed pelvic organ prolapse and urinary incontinence in a population-based cohort, and to describe their clinical characteristics. METHODS: Our retrospective cohort study included all patients undergoing surgical treatment for prolapse and incontinence during 1995; all were members of Kaiser Permanente Northwest, which included 149,554 women age 20 or older. A standardized data-collection form was used to review all inpatient and outpatient charts of the 395 women identified. Variables examined included age, ethnicity, height, weight, vaginal parity, smoking history, medical history, and surgical history, including the preoperative evaluation, procedure performed, and details of all prior procedures. Analysis included calculation of age-specific and cumulative incidences and determination of the number of primary operations compared with repeat operations performed for prolapse or incontinence. RESULTS: The age-specific incidence increased with advancing age. The lifetime risk of undergoing a single operation for prolapse or incontinence by age 80 was 11.1%. Most patients were older, postmenopausal, parous, and overweight. Nearly half were current or former smokers and one-fifth had chronic lung disease. Reoperation was common (29.2% of cases), and the time intervals between repeat procedures decreased with each successive repair. CONCLUSION: Pelvic floor dysfunction is a major health issue for older women, as shown by the 11.1% lifetime risk of undergoing a single operation for pelvic organ prolapse and urinary incontinence, as well as the large proportion of reoperations. Our results warrant further epidemiologic research in order to determine the etiology, natural history, and long-term treatment outcomes of these conditions.

Purification and characterization of a proline-rich antibacterial peptide, with sequence similarity to bactenecin-7, from the haemocytes of the shore crab, Carcinus maenas.

Antibacterial peptides are important for non-specific host defence in many animals. They have been extensively characterized from mammals, amphibians, insects and chelicerates but have not so far been found in crustaceans. Here we report the presence of several constitutive antibacterial proteins, active against both gram-positive and gram-negative bacteria, in the haemocytes of the shore crab, Carcinus maenas. These proteins have molecular masses of > 70 kDa, approximately 45 kDa, approximately 14 kDa and 6.5 kDa. The 6.5 kDa peptide has been purified to homogeneity by Sep Pak C18 extraction, gel filtration and reverse-phase HPLC. Partial N-terminal sequence analysis further shows that it is proline rich and shares more than 60% identity in a 28-amino-acid overlap with the mature form of bactenecin 7, an antimicrobial peptide from bovine neutrophils which belongs to the cathelicidin family of mammalian peptide antibiotics.

Antibacterial Properties of Isolated Amoebocytes From the Sea Anemone Actinia equina.

The antimicrobial defenses of anthozoans were investigated in vitro by extracting amoebocytes from the mesenteric filaments of the beadlet anemone, Actinia equina, and testing for their ability to phagocytose and kill the gram-negative bacterium Psychrobacter immobilis. Only the hyaline amoebocytes exhibited phagocytosis in vitro, with about 40% seen to ingest one or more bacteria over 45 min. Mixed cultures of viable amoebocytes were further found to produce O2- ions and other reactive oxygen species (ROS) after stimulation with phorbol myristate acetate or lipopolysaccharide. Co-incubation of viable amoebocytes with P. immobilis for 3 h in vitro resulted in reduced growth of the bacterium compared to saline-incubated bacteria, but because the growth of P. immobilis was also impaired by lysed control amoebocytes, the contribution made to bacterial killing by ROS could not be evaluated. Instead, as confirmed by additional experiments using lysate supernatants of the amoebocytes, it appears that the cells contain soluble bactericidal factors. The nature of these agents is at present unknown, although preliminary tests indicate that killing is not mediated by lysozyme.

Proliferation of undifferentiated blood cells from the solitary ascidian, Ciona intestinalis in vitro.

The proliferative responses of the cytotoxic blood cell population of the solitary ascidian, Ciona intestinalis, were investigated by autoradiography and tritiated thymidine (3H-TdR) incorporation following treatment with mitogens or co-culture with allogeneic cells in vitro. A small number of mitotic figures were seen in untreated circulating blood cells and pulse labelling with 3H-TdR showed that only the undifferentiated "lymphocyte-like" cells within the enriched cytotoxic cell population undergo spontaneous cell division and DNA synthesis in the circulation. Treatment of the cells, cultured for 4 days, with concanavalin A (con A), phytohaemagglutinin-B (PHA-B) or lipopolysaccharide (LPS) produced significantly increased 3H-TdR incorporation, although there were differences in the sensitivity of the cells to mitogen concentration. Significantly enhanced proliferation was also observed following incubation with mitomycin C-treated cells from allogeneic individuals. These results show that the cytotoxic blood cell population of C. intestinalis is capable of mitogen-induced proliferation as well as mixed lymphocyte-type responses and therefore shares some proliferative characteristics with vertebrate lymphocytes.