Seagrass wasting disease: Nitrate enrichment and exposure to a herbicide (Diuron) increases susceptibility of Zostera marina to infection.

Seagrass meadows suffered large-scale declines in the past century. The 'wasting disease', pathognomonically associated with Labyrinthula zosterae, reduced populations of Zostera marina on both sides of the North Atlantic in, and since, the 1930s, coinciding with intensive agricultural use of artificial fertilizers and herbicides. This study tests the long-standing hypothesis that nutrient enrichment and a herbicide increases vulnerability to pathogens. Z. marina shoots from the Thames Estuary grown in elevated nitrate concentrations had significantly higher rates of infection by L. zosterae than controls, but not by Aplanochytrium sp., another slime-mould like protist. Z. marina shoots grown in 2µg·l-1 Diuron solutions and infected separately by L. zosterae and Aplanochytrium sp. had significantly higher wasting indices than controls. The results identified Aplanochytrium sp. as another opportunistic pathogen causing a seagrass wasting-type disease and support the hypothesis that pollution by herbicides and nitrate increases the susceptibility of Z. marina to infections.

The effect of sewage pollution on the feeding behaviour and diet of Hediste (Nereis diversicolor (O.F. Müller, 1776)) in three estuaries in south-east England, with implications for saltmarsh erosion.

Stable isotope analyses of the abundant infaunal polychaete Hediste diversicolor, recognised as an indicator of sewage pollution, support the hypothesis that nutrient enrichment promotes surface deposit feeding, over suspension feeding and predation. At sewage-polluted sites in three estuaries in SE England Hediste mainly consumed microphytobenthos, sediment organic matter and filamentous macroalgae Ulva spp. At cleaner sites Hediste relied more on suspension feeding and consumption of Spartina anglica. There were no consistent differences in Hediste densities between the polluted and cleaner sites, probably because of increased densities at the cleaner sites too, facilitated by the planting of Spartina and nitrogen enrichment there too, including from agricultural run-off. Increased nutrient enrichment and the artificial availability of Spartina have probably increased densities of, and deposit-feeding by, Hediste in the past half-century and contributed indirectly to saltmarsh losses, since deposit-feeding by Hediste has been implicated in recent saltmarsh erosion in SE England.

Diagnostic and mechanistic implications of serum free light chains, albumin and alpha-fetoprotein in hepatocellular carcinoma.

BACKGROUND: Mass spectroscopy analysis suggested low serum albumin and high immunoglobulin free light chain (sFLC) levels may have diagnostic value in hepatocellular carcinoma (HCC). Our aims were to apply quantitative assays to confirm these observations, determine their diagnostic utility, and investigate the mechanisms involved. METHODS: Albumin, sFLC, routine liver and renal function tests were measured in patients with chronic liver disease with (n=102) and without (n=113) HCC. The discriminant performance was compared with the current standard serological test alpha-fetoprotein (AFP) using receiver operating characteristic (ROC) and area under the curve (AUC) analyses. RESULTS: sFLC and serum albumin were each confirmed to have discriminatory utility in HCC with AUC values of 0.7 and 0.8, respectively. sFLC were strongly correlated with gammaglobulin levels and both these were inversely related to serum albumin levels. The discriminatory utility of sFLC was retained after adjusting for renal and liver function. CONCLUSIONS: Serum levels of sFLC and albumin were strongly associated with HCC as predicted by mass spectroscopy. Discrimination of HCC by AFP was improved by the addition of either albumin or sFLC. Larger prospective studies are required to determine how AFP, sFLC and albumin might be combined in a useful diagnostic approach for HCC.

Ethnic variation in maternity care: a comparison of Polish and Scottish women delivering in Scotland 2004-2009.

OBJECTIVES: Birth outcomes in migrants vary, but the relative explanatory influence of obstetric practice in origin and destination countries has been under-investigated. To explore this, birth outcomes of Scots and Polish migrants to Scotland were compared with Polish obstetric data. Poles are the largest group of migrants to Scotland, and Poland has significantly more medicalized maternity care than Scotland. STUDY DESIGN: A population-based epidemiological study of linked maternal country of birth, maternity and birth outcomes. METHODS: Scottish maternity and neonatal records linked to birth registrations were analysed for differences in modes of delivery and pregnancy outcomes between Polish migrants and Scots, and compared with Polish Health Fund and survey data. RESULTS: 119,698 Scottish and 3105 Polish births to primiparous women in Scotland 2004-9 were analysed. Poles were less likely than Scots to have a Caesarean section and more likely to have a spontaneous vaginal or instrumental delivery. The Caesarean section rate in Poland is significantly higher and instrumental delivery rate lower than for either group of women in Scotland. CONCLUSIONS: Methodologically, comparing a large group of migrants from one country with the host population has advantages over grouping migrants from several countries into a single category, and allows more informed analysis of the effect of health services. Polish mothers' being slightly healthier explains some of their lower Caesarean section rate compared to Scots in Scotland. However, dominant models of obstetrics in the two countries seem likely to influence the differences between Poles delivering in Poland and Scotland. Further investigation of both is required.

The relationship between high-sensitivity CRP and polyclonal free light chains as markers of inflammation in chronic disease.

INTRODUCTION: Serum concentrations of polyclonal free light chains (FLC) represent the activity of the adaptive immune system. This study assessed the relationship between polyclonal FLC and the established marker of innate immunity, C-reactive protein (CRP), in chronic and acute disease. METHODS: We utilized four cross-sectional chronic disease patient cohorts: chronic kidney disease (CKD), diabetes, vasculitis and kidney transplantation; and a longitudinal intensive care case series to assess the kinetics of production in acute disease. RESULTS: There was a weak association between polyclonal FLC and high-sensitivity CRP (hs-CRP) in the study cohorts. A longitudinal assessment in acute disease showed a gradual increase in FLC concentrations over time, often when CRP levels were falling, demonstrating clear differences in the response kinetics of CRP and FLC in this setting. CONCLUSION: Polyclonal FLC and hs-CRP provide independent information as to inflammatory status. Prospective studies are now required to assess the utility of hs-CRP and polyclonal FLC in combination for risk stratification in disease populations.

Screening for gestational diabetes mellitus: cost-utility of different screening strategies based on a woman's individual risk of disease.

AIMS/HYPOTHESIS: The cost-effectiveness of eight strategies for screening for gestational diabetes (including no screening) was estimated with respect to the level of individual patient risk. METHODS: Cost-utility analysis using a decision analytic model populated with efficacy evidence pooled from recent randomised controlled trials, from the funding perspective of the National Health Service in England and Wales. Seven screening strategies using various combinations of screening and diagnostic tests were tested in addition to no screening. The primary outcome measure was the incremental cost per quality-adjusted life-year (QALY) over a lifetime. RESULTS: The strategy that has the greatest likelihood of being cost-effective is dependent on the risk of gestational diabetes mellitus for each individual woman. When gestational diabetes mellitus risk is <1% then the no screening/treatment strategy is cost-effective; where risk is between 1.0% and 4.2% fasting plasma glucose followed by OGTT is most likely to be cost-effective; and where risk is >4.2%, universal OGTT is most likely to be cost-effective. However, acceptability of the test alters the most cost-effective strategy. CONCLUSIONS/INTERPRETATION: Screening for gestational diabetes can be cost-effective. The best strategy is dependent on the underlying risk of each individual and the acceptability of the tests used. The current study suggests that if a woman's individual risk of gestational diabetes could be accurately predicted, then healthcare resource allocation could be improved by providing an individualised screening strategy.

Papillary carcinoma in a male breast cyst: a diagnostic challenge.

Intracystic papillary breast carcinoma is a rare form of non-invasive carcinoma with an excellent prognosis. It accounts for less than 0.5% of breast cancers. We report the case of a 75-year-old man presenting with a painless cystic lump in the right breast. Ultrasonography showed a cystic lesion and aspiration revealed blood-stained fluid with suspicion of malignancy. Excisional biopsy was necessary to confirm the diagnosis and also indicated that local treatment was adequate.

Environmental influences on helminthiasis and nutritional status among Pacific schoolchildren.

This paper describes a study undertaken to: (1) determine the prevalence of Ascaris lumbricoides, Trichuris trichiura and hookworm infections and nutritional status among Pacific Island school children; (2) identify factors influencing helminthiasis; (3) identify interventions to improve school health. A total of 3,683 children aged 5-12 years attending 27 primary schools in 13 Pacific Island countries were surveyed along with school environmental data. Stool samples were collected from 1996 children (54.2%) and analysed for ova and helminths. Total prevalence of helminthiasis was 32.8%. Anaemia prevalence was 12.4%. Children with helminthiasis and anaemia were found to be 8.7 times more likely to be stunted and 4.3 times more likely to be underweight than non-anaemic and non-infected children. Four significant environmental influences on helminthiasis were identified: (1) an inadequate water supply; (2); availability of a school canteen; (3) regular water/sanitation maintenance regimes; and (4) overcrowded classrooms. Helminthiasis was found to be strongly associated with anaemia, stunting and underweight and environmental influences identified. Although mass anti-helminthic drug administrations (MDA) have been taking place, reinfection is common as drug therapy alone is not enough. Programme effectiveness depends upon upgrading school environments to include an adequate water supply, controlled food preparation/provision, well-maintained water/sanitation facilities and class sizes of 30 students or less.

Serum IgA and IgG functional antibodies and their subclasses to Streptococcus pneumoniae capsular antigen found in two aged-matched cohorts of children with and without otitis media with effusion.

The relationship between acute otitis media and otitis media with effusion (OME) is uncertain and the aetiology of OME is multifactorial. Otitis media with effusion may be an inflammatory condition; both bacteria and viral infections could play a part in this inflammation. The four bacteria Streptococcus pneumoniae, Haemophilus influenza, Staphylococcus aureus and Branhamella catarrhalis cause 60% of the infections whereas S. pneumoniae accounts for up to 35%. IgA provides the dominant surface response to polysaccharide and lipopolysaccharide antigens, of which IgA2 is the main subclass. Once the mucosa has been breached, most protection is provided by IgG. IgG2 acts mainly against bacterial capsular antigens. This study looked at two groups of 50 children with and without OME who were aged between 3 and 10 years. The aims were to determine if, firstly, the levels of the serum immunoglobulins were different in the two groups, secondly whether these children made the appropriate antibody response to the capsular antigen to S. pneumoniae (PCP), and finally if there was a delay in the maturity of the IgA response. The total IgG, IgA and all subclass levels were measured using radial immunodiffusion. Levels of functional IgA and IgG were measured using ELISAs (25 patients in each group). The results were analysed with non-parametric tests. The immunoglobulin levels were within the normal levels for both groups. There were very good correlations between the IgG total anti-PCP and the IgG2 anti-PCP (R > 0.9, p = 0.001). There was a good correlation between the levels of both IgG total and IgG2 anti-PCP against IgA total anti-PCP in both groups (R > 0.85, p > 0.01). This confirms a normal antibody response between both groups of patients. The ages of the controls and patients (50 samples) were correlated with increasing titres of circulating functional antibodies (P = 0.001). This is highly suggestive of a normal age-related response. In conclusion, the findings were contradictory to our original hypothesis that there is a subtle difference in surface protection between children with and without OME. We believe that a previous history of recurrent acute otitis media is unrelated to the development of OME after 3 years of age.

Racial and ethnic differences in access to medical care in managed care plans.

OBJECTIVE: To examine the extent to which access differences between racial/ethnic minorities and whites in managed care plans are greater than such differences in other types of health plans. DATA SOURCE: A nationally representative sample of 4,811 African American, 3,379 Hispanic, and 33,737 white nonelderly persons with public or private health insurance. STUDY DESIGN/DATA COLLECTION: A cross-sectional survey of households was conducted during 1996 and 1997. Commonly used measures of access to and utilization of medical care were constructed for individuals: (1) percentage of visits with a usual provider, (2) percentage with a regular provider, (3) visit with a physician in the past year, (4) hospital ER use, (5) last visit was to a specialist. PRINCIPAL FINDINGS: Fewer than 74 percent of Hispanics and African Americans had a regular provider compared to more than 78 percent of white Americans. Hispanics were least likely to have had their last doctor visit with a specialist (22 percent) compared to African Americans (26 percent) and whites (28 percent). Differences between ethnic/racial minorities and whites in managed care plans are similar to differences observed in non-managed care plans. Americans of all racial and ethnic backgrounds in managed care plans with gatekeeping are more likely to have a usual source of care, a regular provider, and lower use of specialists compared to persons in plans without gatekeeping. CONCLUSION: Although greater access to primary care was shown among African Americans and Hispanics in managed care plans, the extent of the disparities between racial/ethnic minorities and whites in managed care is similar to disparities in other types of health plans.

Nasal manifestations of granulomatous disease.

Granulomatous disease frequently affects the head and neck region, particularly the nose and sinuses. This article describes the most common infectious and non-infectious conditions and their clinical features.

Inequality in America: the contribution of health centers in reducing and eliminating disparities in access to care.

Reducing and eliminating health status disparities by providing access to appropriate health care is a goal of the nation's health care delivery system. This article reviews the literature that demonstrates a relationship between access to appropriate health care and reductions in health status disparities. Using comprehensive site-level data, patient surveys, and medical record reviews, the authors present an evaluation of the ability of health centers to provide such access. Access to a regular and usual source of care alone can mitigate health status disparities. The safety net health center network has reduced racial/ethnic, income, and insurance status disparities in access to primary care and important preventive screening procedures. In addition, the network has reduced low birth weight disparities for African American infants. Evidence suggests that health centers are successful in reducing and eliminating health access disparities by establishing themselves as their patients' usual and regular source of care. This relationship portends well for reducing and eliminating health status disparities.

Hypersensitive allergic reactions to bismuth-iodoform-paraffin paste following ear surgery.

The case notes of 185 patients who had bismuth-iodoform-paraffin paste (BIPP) impregnated ribbon gauze used for packing following ear surgery were analysed retrospectively. The incidence of hypersensitive allergic reactions to BIPP was 5.9 per cent and a five-fold increase risk of developing allergic reactions was found in those with previous exposure to BIPP. Where temporalis fascia was used to repair tympanic membrane defects, the incidence of tympanic membrane graft perforations was higher when allergic reactions to BIPP developed post-operatively, compared to non-allergic cases.

The role of nasal endoscopy in outpatient management.

The data from 140 consecutive patients who had undergone computerized tomography (CT) as part of their investigation for nasal symptoms, and who had been examined by one surgeon, were retrospectively reviewed. The history, rhinoscopic findings, endoscopic findings, changes on CT and final diagnosis were noted. Endoscopy was found to identify more disease than rhinoscopy (85% versus 74%); and a similar picture was seen when combining history with either endoscopy or rhinoscopy. Endoscopic examination was found to have a sensitivity of 84% and a specificity of 92%. In 25 (18%) patients endoscopy contributed positively towards a correct diagnosis, but in 11 (8.0%) there were false positive findings. CT findings led to a re-evaluation of the diagnosis and alteration of management of these 11 individuals who had false positive endoscopic findings. History alone led to an accurate diagnosis in 84% of patients with inflammatory nasal conditions. The role of the endoscope is best considered as 'fine tuning'; and supplementary to a detailed history.

Vocal fold abductor paralysis as a solitary and fatal manifestation of multiple system atrophy.

A patient is presented who had bilateral abductor vocal fold paralysis pathologically proven to be due to multiple system atrophy (MSA) in the absence of other neurological features. MSA is a degenerative neurological condition that includes olivopontocerebellar atrophy, Shy-Drager syndrome and striatonigral degeneration. The usual predominant features of MSA are cerebellar ataxia, autonomic dysfunction and Parkinsonism. Stridor is present in over one third of patients and has been reported previously as a presenting symptom in MSA: however previously reported patients have always gone on to develop other neurological symptoms. The usual investigations of bilateral abductor vocal fold paralysis caused by MSA will not reveal the pathological process and we believe that magnetic resonance imaging (MRI) of the medulla and brain stem and autonomic function tests are probably the investigations of choice. It is a worthwhile exercise attempting to identify MSA as the cause of stridor as the prognosis is good in the medium term if appropriate support is offered.

Conservative management of splenic rupture in a haemophiliac adult.

The recognition of the grave risk of overwhelming sepsis in splenectomized individuals has led to the search for alternatives to splenectomy. Conservative management, first tried successfully in children and later extended to adult patients, has become the accepted form of treatment and has also been tried with success in haemophiliac children. The case presented here is important because this is the first report of a successful outcome of non-operative treatment of a ruptured spleen in a haemophiliac adult.