Doctors' attitudes to patient occupation information in four hospital specialties.

BACKGROUND: Although we do not know how often doctors enquire about their patients' work, evidence suggests that occupation is often not recorded in clinical notes. There is a lack of research into doctors' views on the importance of patient occupation or their educational needs in this area. AIMS: To assess doctors' attitudes to using patient occupation information for care-planning and to determine doctors' need for specific training in occupational health. METHODS: We undertook a cross-sectional survey of doctors in cardiology, obstetrics and gynaecology, oncology and orthopaedics. Our questionnaire explored attitudes of the doctors to asking patients about their occupational status, their training and competency to do so, and their training needs in occupational health. RESULTS: The response rate was 42/46 (91%). Obstetrics and gynaecology 6/9 (67%) and oncology doctors 3/6 (50%) reported enquiring about the nature of patients' occupations' 'most of the time'/'always' and that it rarely influenced clinical decisions. This contrasted with orthopaedic doctors 12/12 (100%) and cardiology doctors 14/15 (93%). Although 19/42 (45%) participants felt it was important to ask patients their occupation, only 10/42 (24%) 'always' asked patients about their work. The majority of participants 29/41 (71%) reported receiving no training in occupational health, but 37/42 (88%) considered that some training would be useful. CONCLUSIONS: Training on the importance of occupation and its' role as a clinical outcome in care-planning, might help doctors feel more competent in discussing the impact of health on work with patients.

Recombination of the Phase-Variable spnIII Locus Is Independent of All Known Pneumococcal Site-Specific Recombinases.

Streptococcus pneumoniae is one of the world's leading bacterial pathogens, causing pneumonia, septicemia, and meningitis. In recent years, it has been shown that genetic rearrangements in a type I restriction-modification system (SpnIII) can impact colony morphology and gene expression. By generating a large panel of mutant strains, we have confirmed a previously reported result that the CreX (also known as IvrR and PsrA) recombinase found within the locus is not essential for hsdS inversions. In addition, mutants of homologous recombination pathways also undergo hsdS inversions. In this work, we have shown that these genetic rearrangements, which result in different patterns of genome methylation, occur across a wide variety of serotypes and sequence types, including two strains (a 19F and a 6B strain) naturally lacking CreX. Our gene expression analysis, by transcriptome sequencing (RNAseq), confirms that the level of creX expression is impacted by these genomic rearrangements. In addition, we have shown that the frequency of hsdS recombination is temperature dependent. Most importantly, we have demonstrated that the other known pneumococcal site-specific recombinases XerD, XerS, and SPD_0921 are not involved in spnIII recombination, suggesting that a currently unknown mechanism is responsible for the recombination of these phase-variable type I systems.IMPORTANCEStreptococcus pneumoniae is a leading cause of pneumonia, septicemia, and meningitis. The discovery that genetic rearrangements in a type I restriction-modification locus can impact gene regulation and colony morphology led to a new understanding of how this pathogen switches from harmless colonizer to invasive pathogen. These rearrangements, which alter the DNA specificity of the type I restriction-modification enzyme, occur across many different pneumococcal serotypes and sequence types and in the absence of all known pneumococcal site-specific recombinases. This finding suggests that this is a truly global mechanism of pneumococcal gene regulation and the need for further investigation of mechanisms of site-specific recombination.

Mutation and Selection in Bacteria: Modelling and Calibration.

Temporal evolution of a clonal bacterial population is modelled taking into account reversible mutation and selection mechanisms. For the mutation model, an efficient algorithm is proposed to verify whether experimental data can be explained by this model. The selection-mutation model has unobservable fitness parameters, and, to estimate them, we use an Approximate Bayesian Computation algorithm. The algorithms are illustrated using in vitro data for phase variable genes of Campylobacter jejuni.

Coadministration of the Campylobacter jejuni N-Glycan-Based Vaccine with Probiotics Improves Vaccine Performance in Broiler Chickens.

Source attribution studies report that the consumption of contaminated poultry is the primary source for acquiring human campylobacteriosis. Oral administration of an engineered Escherichia coli strain expressing the Campylobacter jejuni N-glycan reduces bacterial colonization in specific-pathogen-free leghorn chickens, but only a fraction of birds respond to vaccination. Optimization of the vaccine for commercial broiler chickens has great potential to prevent the entry of the pathogen into the food chain. Here, we tested the same vaccination approach in broiler chickens and observed similar efficacies in pathogen load reduction, stimulation of the host IgY response, the lack of C. jejuni resistance development, uniformity in microbial gut composition, and the bimodal response to treatment. Gut microbiota analysis of leghorn and broiler vaccine responders identified one member of Clostridiales cluster XIVa, Anaerosporobacter mobilis, that was significantly more abundant in responder birds. In broiler chickens, coadministration of the live vaccine with A. mobilis or Lactobacillus reuteri, a commonly used probiotic, resulted in increased vaccine efficacy, antibody responses, and weight gain. To investigate whether the responder-nonresponder effect was due to the selection of a C. jejuni "supercolonizer mutant" with altered phase-variable genes, we analyzed all poly(G)-containing loci of the input strain compared to nonresponder colony isolates and found no evidence of phase state selection. However, untargeted nuclear magnetic resonance (NMR)-based metabolomics identified a potential biomarker negatively correlated with C. jejuni colonization levels that is possibly linked to increased microbial diversity in this subgroup. The comprehensive methods used to examine the bimodality of the vaccine response provide several opportunities to improve the C. jejuni vaccine and the efficacy of any vaccination strategy.IMPORTANCECampylobacter jejuni is a common cause of human diarrheal disease worldwide and is listed by the World Health Organization as a high-priority pathogen. C. jejuni infection typically occurs through the ingestion of contaminated chicken meat, so many efforts are targeted at reducing C. jejuni levels at the source. We previously developed a vaccine that reduces C. jejuni levels in egg-laying chickens. In this study, we improved vaccine performance in meat birds by supplementing the vaccine with probiotics. In addition, we demonstrated that C. jejuni colonization levels in chickens are negatively correlated with the abundance of clostridia, another group of common gut microbes. We describe new methods for vaccine optimization that will assist in improving the C. jejuni vaccine and other vaccines under development.

The surgical management of sarcomas of the chest wall: A 13-year single institution experience.

INTRODUCTION: Chest wall sarcomas are rare. Resection and reconstruction pose significant anatomical and functional challenges. We present our experience of managing these tumours as plastic surgeons working within a specialist sarcoma MDT. METHODS: All cases of chest wall sarcoma in which a plastic surgeon took part were analysed (2003-2016). Tumours of the breast, abdomen and groin were excluded. Demographics, surgical details and outcomes were analysed. RESULTS: Forty-seven patients were identified. Median age at presentation was 61 years (range 7-91). Thirty-three were male and 14 were female. Chondrosarcoma (n = 16) was the most frequently occurring tumour, followed by myxofibrosarcoma (n = 6), leiomyosarcoma (n = 5) and unclassified sarcomas (n = 5). The majority of tumours were of high (n = 16) or intermediate grade (n = 17) histologically. Wide local excision was carried out in all cases. Twenty-two cases required a mesh and cement reconstruction of the chest wall. Soft tissue reconstruction involved pedicled LD flap +-skin graft (n = 17), direct closure (n = 13), pedicled VRAM (n = 7), free ALT flap (n = 6), and others (n = 4). Clear resection margins were achieved in 32 patients (68%). Fourteen patients underwent adjuvant radiotherapy and four adjuvant chemotherapy. Nine patients (19%) developed a local recurrence, and the median duration from resection to recurrence was 17 months (range 3-72). Nine patients (19%) developed metastasis. Eleven patients died (23.4%), and the median duration of survival 30 months (range 3-92). Thirty-six patients remain well, with a median duration of follow up 57.5 months (range 6-141). Estimated 5 year disease specific survival is 74.2%. CONCLUSION: Plastic surgeons have a vital role in the management of chest wall sarcomas. We present a reconstructive algorithm, which has enabled us to achieve good oncological and functional outcomes and a low complication profile .

Autologous olfactory ensheathing cell transplantation in human paraplegia: a 3-year clinical trial.

Olfactory ensheathing cells show promise in preclinical animal models as a cell transplantation therapy for repair of the injured spinal cord. This is a report of a clinical trial of autologous transplantation of olfactory ensheathing cells into the spinal cord in six patients with complete, thoracic paraplegia. We previously reported on the methods of surgery and transplantation and the safety aspects of the trial 1 year after transplantation. Here we address the overall design of the trial and the safety of the procedure, assessed during a period of 3 years following the transplantation surgery. All patients were assessed at entry into the trial and regularly during the period of the trial. Clinical assessments included medical, psychosocial, radiological and neurological, as well as specialized tests of neurological and functional deficits (standard American Spinal Injury Association and Functional Independence Measure assessments). Quantitative test included neurophysiological tests of sensory and motor function below the level of injury. The trial was a Phase I/IIa design whose main aim was to test the feasibility and safety of transplantation of autologous olfactory ensheathing cells into the injured spinal cord in human paraplegia. The design included a control group who did not receive surgery, otherwise closely matched to the transplant recipient group. This group acted as a control for the assessors, who were blind to the treatment status of the patients. The control group also provided the opportunity for preliminary assessment of the efficacy of the transplantation. There were no adverse findings 3 years after autologous transplantation of olfactory ensheathing cells into spinal cords injured at least 2 years prior to transplantation. The magnetic resonance images (MRIs) at 3 years showed no change from preoperative MRIs or intervening MRIs at 1 and 2 years, with no evidence of any tumour of introduced cells and no development of post-traumatic syringomyelia or other adverse radiological findings. There were no significant functional changes in any patients and no neuropathic pain. In one transplant recipient, there was an improvement over 3 segments in light touch and pin prick sensitivity bilaterally, anteriorly and posteriorly. We conclude that transplantation of autologous olfactory ensheathing cells into the injured spinal cord is feasible and is safe up to 3 years of post-implantation, however, this conclusion should be considered preliminary because of the small number of trial patients.

Cytological and enzymological characterization of adult human adipocyte precursors in culture.

Cell strains were derived from the stromal-vascular fraction of human omental adipose tissue and grown in culture. Since the purpose of this study was to isolate adipocyte precursors from adults, the cells were obtained from nonobese patients 40-60 yr of age. After treatment of adipose tissue with collagenase, mature adipocytes were separated from stromal-vascular fraction cells, and cell strains of the latter replicated in culture with a doubling time of 40-60 h. They were initially fusiform; upon reaching monolayer confluency, they accumulated lipid and became rounder. Skin fibroblasts from the same patients and grown under the same culture conditions remained fusiform and did not accumulate lipid. The stromal-vascular fraction cells of adipose tissue may be fibroblasts with the potential to become adipocyte precursors. Subcellular preparations of the cells grown from the stromal-vascular fraction revealed lipoprotein lipase activity (characterized by such properties as inhibition by 1 M NaCl) that was not detectable in skin fibroblasts. The overall specific activity of the enzymes that catalyze triglyceride synthesis was 15 times higher and that of fatty acid synthetase was 2 times higher in the cells cultured from the stromal-vascular fraction. The difference was significant in each case. Conversely, when isolated mature adipocytes were cultured, they lost considerable lipid and acquired morphological characteristics similar to those of stromal-vascular fraction cells. Thus, adipose tissue stromal-vascular fraction cells acquire in culture many of the morphological and enzymological characteristics of mature fat cells.

Long-term dinoflagellate culture performance in a commercial photobioreactor: Amphidinium carterae case.

The aim of this work was to study the culture performance of a dinoflagellate in a commercial photobioreactor. The results obtained during this long-term experiment allow to confirm that Amphidinium carterae is a promising dinoflagellate that can be exploited successfully in closed systems, in semi-continuous mode in indoor and outdoor environments. The average results in an indoor 5cm light-path 320L photobioreactor were, in terms of specific growth rate (0.29d(-1)), duplication time (3.1d(-1)) and dry biomass productivity (78mgL(-1)d(-1)). Specific compounds production was found including ω3 and ω6 fatty acids and, pigments (Peridinin, ß-carotene). These promising results, besides unique characteristics found during the exploitation period such as resistance to mechanical stress, self-control of contaminant organisms, and quick cells aggregation when the culture is not in turbulence conditions, makes A. carterae one of the new target species suitable for commercially exploitation on an industrial scale.

Evaluation of batch and semi-continuous culture of Porphyridium purpureum in a photobioreactor in high latitudes using Fourier Transform Infrared spectroscopy for monitoring biomass composition and metabolites production.

The culture strategy (batch or semi-continuous) was evaluated for biomass and metabolite formation in Porphyridium purpureum cultures in higher latitudes (>50° N). FTIR was used technology to characterise macromolecule biomass composition and the quality of the metabolites produced. Semi-continuous culture was found to be the most feasible strategy to develop microalgal biomass production facilities in higher latitudes, due to their average results in terms of growth rate (0.27 day(-1)), duplication time (2.5-4 days), maximum cell density achieved (1.43*10(7) cells m L(-1)), biomass productivity of 47.04 mg L(-1) day(-1) and an exopolysaccharides production of 2.1 g L(-1). FTIR technology applied to microalgal production is a valuable and reliable tool to determine on a daily basis not just the evolution of macromolecules composition (lipids, carbohydrates and proteins) but also for the characterisation of the metabolites produced such as phycoerythrin or exopolysaccharides in P. purpureum cultures.

Pentamidine-induced hypoglycemia in patients with the acquired immune deficiency syndrome.

We conducted an analysis of 37 patients with the acquired immune deficiency syndrome (AIDS) who received pentamidine for the treatment of Pneumocystis carinii pneumonia to quantitate the incidence and severity of pentamidine-induced hypoglycemia. Ten of these patients (27%), nine of whom were symptomatic, developed hypoglycemia during or shortly after pentamidine therapy. The mean nadir blood glucose concentration in those who developed hypoglycemia during or shortly after pentamidine therapy was 38 mg/dl (range 20 to 55 mg/dl). The hypoglycemia frequently persisted after the end of pentamidine therapy. The incidence of nephrotoxicity in patients who developed hypoglycemia was 100%, as compared with 38% in the group who remained euglycemic (P less than 0.01). The overall incidence of pentamidine-induced hypoglycemia with AIDS is several-fold higher than previously reported for patients with other immunocompromising diseases who receive pentamidine. We conclude that pentamidine-induced hypoglycemia is a frequent adverse reaction in patients with AIDS and is potentially life-threatening if not recognized.

Concomitant herpes simplex virus type 1 and cytomegalovirus ventriculoencephalitis in acquired immunodeficiency syndrome.

Three patients with the acquired immunodeficiency syndrome (AIDS) had combined infections of the central nervous system, with both herpes simplex virus (HSV) and cytomegalovirus (CMV). All three had a diffuse ventriculoencephalitis documented at postmortem examination. The presence of HSV type 1 and CMV was confirmed microscopically with immunohistochemistry. The clinical importance of these three patients is that they establish the presence of concomitant HSV and CMV encephalitis in acquired immunodeficiency syndrome, and suggests the possibility of therapeutic intervention with antiviral drugs that have activity against HSV and/or CMV.

Identification and successful treatment of congenital microfistulas with the aid of directional Doppler.

Hitherto unidentifiable and therefore untreatable congenital microfistulas were detected with the aid of continuous-wave directional Doppler and a fine-beam pencil probe. The microfistulas formed part of the Klippel-Trenaunay (K-T) syndrome. The management of one case is reported in detail and in three others salient features are touched upon. Careful clinical and radiological examination failed to demonstrate any arteriovenous microfistulas. When Doppler ultrasound scanning was carried out, two discrete fistulas were discovered. Their extent and direction were mapped out accurately. Incisions were made directly over the markings displaying a pulsating capillary tuft of vessels. Further dissection exposed a feeding arteriole which was less than 1 mm. in diameter. Excision of the vascular malformations resulted in the cure of the patient. In another patient with the K-T syndrome in whom a cutaneous hemangioma involved the whole lower limb, in spite of a thorough and systematic search with a Doppler, no microfistulas could be demonstrated. It is suggested that all patients suffering from the K-T syndrome should be examined by Doppler ultrasound in the hope that microfistulas which elude radiodiagnostic techniques might be detected and treated surgically.

Instability in the faecal flora of a patient suffering from food-related irritable bowel syndrome.

The faecal microbial flora of a patient with severe irritable bowel syndrome related to multiple food intolerances was very variable and contained a high proportion of facultative bacteria and an unusual incidence of Clostridium species.

The faecal flora of two patients with food-related irritable bowel syndrome during challenge with symptom-provoking foods.

The faecal microbial flora of two patients with food-related irritable bowel syndrome was examined while they were on a diet excluding symptom-provoking foods, and then on a diet including such a food. The patients reacted differently to the challenge diet but some changes in faecal output, flora and short chain fatty acid content were seen.

Antiviral therapy for cytomegalovirus retinitis in AIDS with dihydroxy propoxymethyl guanine.

Six patients (all male, five homosexual and one bisexual, 23 to 48 years old) with the acquired immune deficiency syndrome (AIDS) who had cytomegalovirus retinitis were treated with a new antiviral drug as a part of a prospective open-labeled trial for serious cytomegalovirus infections. The drug, 9-[2-hydroxy-1-(hydroxymethyl)ethoxymethyl] guanine (referred to as dihydroxy propoxymethyl guanine), a new acyclic nucleoside antiviral agent similar in structure to acyclovir, produced positive results. These patients treated with dihydroxy propoxymethyl guanine (2.5 mg/kg of body weight every eight hours) showed regression and often disappearance of the lesions of cytomegalovirus retinitis during and for several weeks after therapy, usually with concomitant resolution of viral shedding. The cytomegalovirus retinitis recurred in four patients (the other two were lost to follow-up), but retreatment usually led to remission. Adverse drug toxicity (reversible granulocytopenia) occurred in two patients.

Retention in situ and spectral analysis of fluorescent vacuole components in sections of plant tissues.

The contents of plant vacuoles vary in different organs and with the health of the plant, but little is known of the cell-to-cell distribution of soluble organic compounds within plant tissues. Soluble fluorescent phenolic compounds can be immobilized in plant tissues using an anhydrous freeze-substitution and resin embedment process. The vacuolar fluorescence can be characterized in fluorescence photomicrographs for variations in color and intensity, or more quantitatively with spectra obtained using a microspectrofluorometer. This is demonstrated here in freeze-substituted roots and leaves of soybean. Excitation and emission spectra of individual vacuoles can be compared with spectra of pure compounds to form profiles of the varied phenolic contents of plant vacuoles. Such analyses will add an important anatomical dimension to the study of plant defense and stress responses.

Ureteric obstruction after dacron vascular replacement.

Ureteric obstruction is a recognised complication of aortic bifurcation grafting where the graft material is in close proximity to the ureter as it crosses the common iliac vessels. We have assessed the value of routine postoperative urography in (1) a retrospective 6-year study of ruptured aortic aneurysm repair (11 patients reviewed) and (2) a prospective 18-month study of all patients receiving intra-abdominal dacron grafts (24 assessable patients) in a district general hospital. Renal function was normal in all cases and only 1 ureter was shown at urography to be minimally dilated but not significantly obstructed out of 32 'at risk' ureters in 18 patients in the 2 studies. This complication is uncommon, and no particular advantage can be demonstrated in positioning the ureters either behind or in front of the graft limbs. There is no place for routine urography which should be reserved for the patient with symptoms of ureteric obstruction.

The comparative efficacy and safety of 5% povidone-iodine cream for topical antisepsis.

A 5% povidone-iodine cream (Betadine Cream, The Purdue Frederick Company, Norwalk, Conn.) was tested extensively to determine its safety and efficacy. Results of in vitro microbiologic comparison found that a representative panel of vegetative test organisms couldn't be recovered after 60 seconds or less exposure to povidone-iodine (PVP-I) cream, whereas the kill time of the combination-antibiotic cream (Neosporin Cream, Burroughs Wellcome, Research Triangle Park, NC) exceeded 15 minutes for at least half of vegetative organisms. PVP-I cream produced a log reduction of Bacillus pumilis spores after less than one hour's exposure; the antibiotic cream did not. Both PVP-I and antibiotic creams were essentially non-irritating in human and in vivo animal studies. In open wounds, 5% PVP-I cream caused little or no burning and pain upon application. In human comparisons, artificially induced, standardized lesions inoculated with Staphylococcus aureus, were treated twice daily with PVP-I cream or triple-antibiotic ointment (Neosporin Ointment, Burroughs Wellcome, Research Triangle Park, NC) over three weeks. Both caused significantly reduced bacterial counts (p less than 0.001), and significantly faster healing (p less than 0.05) than no treatment.