Top ten research priorities for spinal cord injury: the methodology and results of a British priority setting partnership.

STUDY DESIGN: This is a mixed-method consensus development project. OBJECTIVES: The objective of this study was to identify a top ten list of priorities for future research into spinal cord injury (SCI). SETTING: The British Spinal Cord Injury Priority Setting Partnership was established in 2013 and completed in 2014. Stakeholders included consumer organisations, healthcare professional societies and caregivers. METHODS: This partnership involved the following four key stages: (i) gathering of research questions, (ii) checking of existing research evidence, (iii) interim prioritisation and (iv) a final consensus meeting to reach agreement on the top ten research priorities. Adult individuals with spinal cord dysfunction because of trauma or non-traumatic causes, including transverse myelitis, and individuals with a cauda equina syndrome (henceforth grouped and referred to as SCI) were invited to participate in this priority setting partnership. RESULTS: We collected 784 questions from 403 survey respondents (290 individuals with SCI), which, after merging duplicate questions and checking systematic reviews for evidence, were reduced to 109 unique unanswered research questions. A total of 293 people (211 individuals with SCI) participated in the interim prioritisation process, leading to the identification of 25 priorities. At a final consensus meeting, a representative group of individuals with SCI, caregivers and health professionals agreed on their top ten research priorities. CONCLUSION: Following a comprehensive, rigorous and inclusive process, with participation from individuals with SCI, caregivers and health professionals, the SCI research agenda has been defined by people to whom it matters most and should inform the scope and future activities of funders and researchers for the years to come. SPONSORSHIP: The NIHR Oxford Biomedical Research Centre provided core funding for this project.

Temporal and Spatial Development of Cercospora Leaf Spot of Faba Bean Influenced by In Situ Inoculum.

The temporal and spatial dynamics of Cercospora leaf spot on susceptible and resistant lines of faba bean grown in or at defined distances from soil with residues infested by Cercospora zonata were examined in South Australia in 2005 and 2006. The disease was first observed on susceptible seedlings 49 days after sowing (DAS) in soil that had been sown with faba bean every 3 years since 1997 (positive soil zone for C. zonata) but was delayed by 1 week in adjacent soil (0 to 16 m away) with no history of cultivation of faba bean (negative soil zone). The incidence of diseased seedlings from 49 to 63 DAS showed a gradient from 4 to 16 m from the infested soil and was significantly greater for susceptible plants grown in the positive versus negative soil zones in field trials conducted in 2005 and 2006 (92 versus 30% in 2005, χ21 = 32.2, P < 0.001; 98 versus 55% in 2006, χ21 = 12.1, P < 0.001). The incidence of Cercospora leaf spot on the resistant line 1322/2 was significantly less (χ26 = 171.7; P < 0.001) than on the susceptible line 'Farah' at that time in both years, with fewer than 5% of the seedlings showing the disease. However, a gradient was shown at 70 to 84 DAS, where disease incidence was significantly greater on line 1322/2 in the positive soil zone than on plants in the negative soil zone in both years (62 and 18%, respectively, with χ21 = 27.9, P < 0.001 in the 2005 trial; and 47 and 6%, respectively, with χ21 = 33.3, P < 0.001 in the 2006 trial). At peak disease severity on Farah, Cercospora leaf spot mean leaf area diseased (%LAD) was severe (85 ± 4.3%) on leaves of the three nodes closest to the soil surface, and much less severe (1 ± 0.6%) in the upper canopy. Defoliation combined with %LAD was used to describe the loss of photosynthetic leaf area (%LPLA) in both cultivars, on both soil zones, in each year. Nonlinear regression analyses using a logistic model described disease development over time on susceptible plants grown in infested soil (e.g., for +12-m blocks within infested soil, y = 2.66 + 46.08/[1 + exp(-0.23 × [X - 40.92])] in 2005 and y = 0.49 + 5.02/[1 + exp(-0.14 × [X - 28.30])] in 2006, where X = DAS and y = %LPLA, with both regressions significant at P < 0.001), whereas an exponential model (e.g., for -12-m blocks from infested soil, y = 0.23 + 0.77 × 1.04X in 2005 and y = 0.44 + 0.56 × 1.04X in 2006, both at P < 0.001) best described disease gradients with increasing distance from the inoculum source. Paired t tests of %LPLA at 77 and 98 DAS showed significant differences in disease severity in the positive versus negative soil zones and a steep gradient in %LPLA from 0 to 4 m from the inoculum source. The role of infested faba bean residue in survival of C. zonata over time was also examined using a pot-bioassay and in situ field assay. When residues were removed from the soil surface or depleted rapidly by animal grazing, the amount of C. zonata inoculum in the soil was significantly less (P < 0.001) than for soil with residue remaining on the soil surface. C. zonata survived in soil and remained infective for at least 30 months after harvest of an infected faba bean crop.

Yield Loss in Cereals, Caused by Fusarium culmorum and F. pseudograminearum, Is Related to Fungal DNA in Soil Prior to Planting, Rainfall, and Cereal Type.

In southeastern Australia, Fusarium crown rot, caused by Fusarium culmorum or F. pseudograminearum, is an increasingly important disease of cereals. Because in-crop control options are limited, it is important for growers to know prior to planting which fields are at risk of yield loss from crown rot. Understanding the relationships between crown rot inoculum and yield loss would assist in assessing the risk of yield loss from crown rot in fields prior to planting. Thirty-five data sets from crown rot management experiments conducted in the states of South Australia and Victoria during the years 2005 to 2010 were examined. Relationships between Fusarium spp. DNA concentrations (inoculum) in soil samples taken prior to planting and disease development and grain yield were evaluated in seasons with contrasting seasonal rainfall. F. culmorum and F. pseudograminearum DNA concentrations in soil prior to planting were found to be positively related to crown rot expression (stem browning and whiteheads) and negatively related to grain yield of durum wheat, bread wheat, and barley. Losses from crown rot were greatest when rainfall during September and October (crop maturation) was below the long-term average. Losses from crown rot were greater in durum wheat than bread wheat and least in barley. Yield losses from F. pseudograminearum were similar to yield losses from F. culmorum. Yield loss patterns were consistent across experiments and between states; therefore, it is reasonable to expect that similar relationships will occur over broad geographic areas. This suggests that quantitative polymerase chain reaction technology and soil sampling could be powerful tools for assessing crown rot inoculum concentrations prior to planting and predicting the risk of yield loss from crown rot wherever this disease is an issue.

The role of the microbiology laboratory in the investigation of child sexual abuse.

Detection of a sexually transmitted pathogen in a child is suggestive of sexual abuse. Consequently, there are very strong clinical, social and legal reasons for diagnosing sexually transmitted disease in children correctly. Carefully considered protocols should be established for all stages of the microbiological investigation. All procedures, from specimen collection to report generation, should be undertaken to the highest possible standard with appropriate documentation. For the more commonly identified sexually transmitted pathogens in the paediatric population, the gold standard of diagnosis in the microbiology laboratory remains culture in vitro because this method offers maximum specificity. Whenever possible, culture must be followed by appropriate confirmatory tests. This highly exacting approach has significant resource and organisational implications and some tests may have to be centralised. The effective provision of an appropriate service for these cases is dependent on the local laboratory collaborating closely with hospital paediatricians and other microbiology laboratories.

Large scale use of ciprofloxacin in the control of a Salmonella outbreak in a hospital for the mentally handicapped.

An outbreak of salmonella food poisoning occurred in a hospital for the mentally handicapped in July 1990. Salmonella enteritidis phage type 4 was identified in 101 patients and eight staff. Standard infection control measures were instituted. Ciprofloxacin was given to all resident patients and to all affected staff. The outbreak was rapidly controlled. There were no new cases after ciprofloxacin was started and there were no clinical relapses. Microbiological relapsers were retreated with ciprofloxacin. A gradual return to normal activity was possible and within two months the hospital was functioning normally. No salmonellae have been identified in the hospital since that time, confirming that the organism was eradicated, rather than just temporarily suppressed.

Infective endocarditis: an epidemiological review of 128 episodes.

OBJECTIVES: The objective was to determine the current epidemiology of infective endocarditis. PATIENTS AND METHODS: All microbiologically positive episodes of infective endocarditis treated at The University Hospital of Wales over a 9-year period from March 1987 to March 1996 was reviewed. Patients originated from the catchment area of The University Hospital of Wales or were referred from other hospitals in Wales. Data extraction was from records held in the Microbiology Department and, whenever possible, from patients' casenotes. The epidemiological parameters were: (1) age and sex of patients; (2) distribution of affected sites; (3) frequency of predisposing risk factors (cardiac and extracardiac); (4) incidence of early prosthetic valve endocarditis; and (5) mortality rates. RESULTS: There were 128 microbiologically positive episodes of endocarditis in 125 patients. The mean age of the population was 53.1 years and the aortic valve was the most frequently involved site of infection (51.6%). A presumed source of infection was identified in 20% if episodes. The commonest predisposing cardiac risk factor in native valve episodes was bicuspid aortic valve (16.7%) but there was no identifiable cardiac risk factor in a much larger proportion (37.7%) of native valve episodes. There was a low incidence (0.6%) of culture positive early prosthetic valve episodes and low mortality rates for both native and prosthetic valve endocarditis (12.3% and 24.5%) in this study. Viridans streptococci were the predominant organisms. In prosthetic valve episodes with onset after the 60th postoperative day but within one postoperative year the identity of the isolate suggested, in most cases, perioperative valve contamination. CONCLUSIONS: The epidemiology of infective endocarditis has undergone significant change. Inability to detect clinically common predisposing lesions, and the frequent absence of any identifiable predisposing cardiac risk factor mean that initial diagnosis is often difficult and demands a high index of suspicion. There was a low incidence of culture positive early prosthetic valve episodes and there were low mortality rates for both native and prosthetic valve endocarditis; these figures suggest improvements in cardiac care. The microbiological evidence indicates that the duration of the postoperative time period used for classifying prosthetic valve endocarditis into 'early' and 'late' episodes should be extended from 60 days to 1 year.

Life threatening Branhamella catarrhalis pneumonia in young infants.

Branhamella catarrhalis is a common nasopharyngeal commensal organism but is also a recognised pathogen. Lower respiratory tract infections caused by this organism have been reported in adults but not, to our knowledge, in otherwise healthy infants. Two infants, born prematurely, suffered near fatal pneumonia. Branhamella catarrhalis was the only microbial pathogen isolated in each case. We suggest that initial antibiotic therapy for severe pneumonia in young infants should be tailored to cover B. catarrhalis infection.

A clinical study of the autorefractor, an antomatic refracting device.

Four hundred eyes were examined with the Autorefractor, an automatic refracting machine, and the results compared with those found by standard techniques of clinical refraction with and without cycloplegia. Agreement was good for spherical power, cylindrical power and spherical equivalents, but less so for cylinder axes.

Globular bodies: a primary cause of the opacity in senile and diabetic posterior cortical subcapsular cataracts?

We examined 9 cataracts from maturity onset diabetics and 4 senile posterior subcapsular cataracts by scanning electron microscopy, transmission electron microscopy, immunofluorescence for crystallin proteins and actin, histochemical methods and x-ray diffraction. The cataractous regions contained spherical globules up to 20 mu in diameter, often in a fibrous matrix. Some were extracellular Morgagnian globules, apparently formed by blebbing from the cell surface; others appeared to have been formed intracellularly. The area of globular degeneration was usually 300 mu deep, but had deeper fusiform extensions. Morphological changes in the cell cytoplasm varied according to their depth in the cataract. Electron microscopy showed intracellular and extracellular globules, many of them were bounded by lipid bilayer membranes. Immunofluorescent staining showed that all the globules contained gamma-crystallin; some contained alpha- and beta-crystallins and actin. All the globules contained higher concentrations of cysteine or cystine than the surrounding lens tissue but they did not react to stains for carbohydrate or calcium. X-ray diffraction studies showed that crystalline calcium salts were absent. Globules and cavities averaged 45% of the total area in cross section. Assuming an area of cataract to be 300 micron thick and that globules 1 mu in diameter scattered, while 2--20 mu in diameter reflected light, we calculated that light passing through such a thickness would be reduced by 65%. Thus the globules could account for most of the opacity of the cataractous area. Presumably the fibrous degeneration of the cells causes enough light scattering to account for the remainder of the reduction. Cataract patients complain of decreased visual acuity, a golden halo around objects, and difficulties when driving while facing oncoming traffic at night. These probably result from light scattering. In our previous experiments, globular bodies containing gamma-crystallin were found in cells grown in tissue culture, and blebs with increased acitn content similar to Morgagnian globules were formed in tissue culture by treating differentiated rat lens cells of stage 2 by cytochalasin D (which impaired microfilament function). These results suggest the possibility of simulating in tissue culture the morphological alterations seen in the cataractous cell.

Ophthalmic assessment by the family physician.

The family physician's basic eye assessment can be carried out with relatively few drugs and instruments. The presenting picture in most patients will fall within one of five categories - redness, discharge and itching, photophobia, pain or visual loss. Causes of these symptoms are described and the therapeutic implications of the more common and simple conditions considered. Other aspects of the eye examination have been considered, including assessment of the anterior chamber, pupillary reaction, ocular motility, measurement of intraocular pressure, and fundoscopy.

[Malignant glaucoma (author's transl)]. / Das maligne Glaukom.

A 35-year-old male, one of three siblings with spherophakia and glaucoma, was treated surgically by aspiration of vitreous through a posterior sclerotomy wound, and air insufflation of the anterior chamber in each eye. Previous peripheral or sector iridectomies were not helpful in contolling the condition. Some improvement was noted with intensive cycloplegic therapy in each eye. In the right eye, one surgical procedure was sufficient to arrest the condition. In the left eye, a sector iridectomy, and three posterior sclerotomies combined with air insufflations of the anterior chamber have been unsuccessful in controlling the pressure. A further sclerotomy with a vitrectomy instrument to remove most of the formed vitreous followed by air insufflation of the anterior chamber is proposed for the uncontrolled eye and if this is not successful in controlling the condition, lens extraction will be carried out.