Total bilirubin assay differences may cause inconsistent treatment decisions in neonatal hyperbilirubinaemia.

OBJECTIVES: To assess interlaboratory variability of total serum bilirubin (TSB) results in newborns. Initiated following a clinical incident in which a neonate was transferred to a tertiary hospital for treatment of severe hyperbilirubinemia but on arrival was reclassified into a lower risk category due to a 20% difference in TSB between laboratories. METHODS: Fresh residual plasma samples from hospital-born infants were pooled to obtain 11 samples across a range of total bilirubin concentrations. Aliquots were light-protected and measured on 7 commercial platforms at 4 accredited medical laboratories. Data from The Royal College of Pathologists of Australasia Quality Assurance Programs' (RCPAQAP) Neonatal Bilirubin program was analysed. RESULTS: Twenty-four to 30% difference in results for individual samples, largely due to calibration differences between assays. When interpreted according to guidelines, results from different platforms would have led to different clinical interventions in some cases. RCPAQAP results showed significant within-method bias but were not shown to be commutable with patient samples. CONCLUSIONS: There are clinically significant method-dependent differences in TSB results from neonatal samples, consistent with our clinical incident. The differences are largely due to lack of standardisation of calibrator values. This has implications for healthcare resource use and possibly for the neurodevelopment of infants. Intervention is needed at a number of levels, including clinical reporting of incidents arising from discordant results, commitment by manufacturers to ensure metrological traceability of methods with sufficiently low uncertainty in the final measurements, and availability of commutable quality assurance material to monitor assay performance, especially at the clinical decision points for neonatal jaundice.

An observation of venous gas emboli in divers and susceptibility to decompression sickness.

INTRODUCTION: Decompression sickness (DCS) results from the formation of bubbles within the tissues and blood in response to a reduction in environmental pressure. Venous gas emboli (VGE) are common after diving and are usually only present in small numbers. Greater VGE numbers are an indication of decompression stress, and can be reliably detected using ultrasound imaging. AIM: To examine the relationship between production of VGE following a routine dive and the risk of DCS. METHODS: A matched population of divers with and without a history of DCS were monitored for the production of VGE at 15-minute intervals using ultrasound, following a 405 kPa air dive in a hyperbaric chamber using the DCIEM air decompression table. VGE production was graded using a validated grading system and the data analysed to compare maximum VGE grade and duration of VGE formation. RESULTS: Eleven divers with a history of DCS were compared with 13 divers with no history of DCS. Divers with a history of DCS demonstrated both a higher maximum grade (P=0.04) and longer duration (P=0.002) of VGE production compared to divers without a history of DCS. CONCLUSION: Higher maximum VGE grades and longer durations of VGE following decompression were associated with a history of DCS and, in particular, musculoskeletal DCS. Although the exact mechanism of DCS remains poorly understood, our data suggest some individuals are inherently more prone to develop VGE, increasing the probability of DCS. Modification of diving practices in those with high VGE grades could potentially decrease DCS risk in these individuals.

Annual influenza vaccination.

Despite national and international recommendations, annual influenza vaccination uptake among health care providers (HCPs) remains sub-optimal. This study investigated the uptake, enablers, and barriers to annual influenza vaccination in medicine, nursing, and physiotherapy students at the University of Notre Dame Australia, Fremantle, using an online survey and semi-structured interviews. In 2013, uptake rate of influenza vaccination was 36.3% (95% CI = 31.8-40.8%). Employment as a HCP (OR 1.6, 95% CI 1.1-2.5), being a medical student (OR 2.5, 95% CI 1.2-5.1) and eligibility for government-funded vaccine (OR 7.1, 95% CI 2.7-18.6) were independently associated with increased uptake. Awareness, cost, and convenience were identified as key barriers to vaccination with interview data suggesting that raising awareness of the benefits of influenza vaccination, along with improving student HCPs' access to affordable, convenient vaccination are likely to improve uptake. Responsibility to increase uptake should be shared between universities and student HCPs.

Tooth use and wear in three iron-biomineralizing mollusc species.

Chitons and limpets harden their teeth with biominerals in order to scrape algae from hard rock surfaces. To elucidate relationships between tooth structure and function, light and electron microscopy were used to examine naturally worn teeth in three species of mollusc with iron-mineralized teeth and to analyze the grazing marks left by members of these species feeding on wax. For the two chiton species, teeth wore down progressively from the medial to the lateral edge of the cusp, while for the limpet, wear was more evenly distributed across the edges of each cusp. In chitons, this pattern of wear matched the medially biased morphology of the cusps in their protracted position and relates to what is known about the mineral composition and substructure of the teeth. The patterns of progressive tooth wear for each of these species, together with the distinct grazing marks left by each species on the wax substrate, indicate that the teeth are designed to remain functionally effective for as long as possible, and have proved to be a valuable means of rationalizing the internal architecture of the teeth at a range of spatial scales. This information is critical for ongoing studies aimed at understanding the interactions between the organic matrix and mineral components of these teeth.

Characterization of biominerals in the radula teeth of the chiton, Acanthopleura hirtosa.

Understanding biomineralization processes provides a route to the formation of novel biomimetic materials with potential applications in fields from medicine to materials engineering. The teeth of chitons (marine molluscs) represent an excellent example of a composite biomineralized structure, comprising variable layers of iron oxide, iron oxyhydroxide and apatite. Previous studies of fully mineralized teeth using X-ray diffraction, Raman spectroscopy and scanning electron microscopy (SEM) have hinted at the underlying microstructure, but have lacked the resolution to provide vital information on fine scale structure, particularly at interfaces. While transmission electron microscopy (TEM) is capable of providing this information, difficulties in producing suitable samples from the hard, complex biocomposite have hindered progress. To overcome this problem we have used focused ion beam (FIB) processing to prepare precisely oriented sections across interfaces in fully mineralized teeth. In particular, the composite structure is found to be more complex than previously reported, with additional phases (goethite and amorphous apatite) and interface detail observed. This combination of FIB processing and TEM analysis has enabled us to investigate the structural and compositional properties of this complex biocomposite at higher resolution than previously reported and has the potential to significantly enhance future studies of biomineralization in these animals.

Ultrastructure of the epithelial cells associated with tooth biomineralization in the chiton Acanthopleura hirtosa.

The cusp epithelium is a specialized branch of the superior epithelium that surrounds the developing teeth of chitons and is responsible for delivering the elements required for the formation of biominerals within the major lateral teeth. These biominerals are deposited within specific regions of the tooth in sequence, making it possible to conduct a row by row examination of cell development in the cusp epithelium as the teeth progress from the unmineralized to the mineralized state. Cusp epithelium from the chiton Acanthopleura hirtosa was prepared using conventional chemical and microwave assisted tissue processing, for observation by light microscopy, conventional transmission electron microscopy (TEM) and energy filtered TEM. The onset of iron mineralization within the teeth, initiated at row 13, is associated with a number of dramatic changes in the ultrastructure of the apical cusp cell epithelium. Specifically, the presence of ferritin containing siderosomes, the position and number of mitochondria, and the structure of the cell microvilli are each linked to aspects of the mineralization process. These changes in tissue development are discussed in context with their influence over the physiological conditions within both the cells and extracellular compartment of the tooth at the onset of iron mineralization.

The chiton stylus canal: An element delivery pathway for tooth cusp biomineralization.

A detailed investigation of the stylus canal situated within the iron mineralized major lateral teeth of the chiton Acanthopleura hirtosa was undertaken in conjunction with a row-by-row examination of cusp mineralization. The canal is shown to contain columnar epithelial tissue similar to that surrounding the mineralized cusps, including the presence of iron rich particles characteristic of the iron storage protein ferritin. Within the tooth core, a previously undescribed internal pathway or plume is evident above the stylus canal, between the junction zone and mineralizing posterior face of the cusp. Plume formation coincides with the appearance of iron in the superior epithelium and the onset of mineralization at tooth row 13. The plume persists during the delivery of phosphorous and calcium into the tooth core, and is the final region of the cusp to become mineralized. The presence of the stylus canal was confirmed in a further 18 chiton species, revealing that the canal is common to polyplacophoran molluscs. These new data strongly support the growing body of evidence highlighting the importance of the junction zone for tooth mineralization in chiton teeth, and indicate that the chemical and structural environment within the tooth cusp is under far greater biological control than previously considered.

Fine structure of the mineralized teeth of the chiton Acanthopleura echinata (Mollusca: Polyplacophora).

The major lateral teeth of the chiton Acanthopleura echinata are composite structures composed of three distinct mineral zones: a posterior layer of magnetite; a thin band of lepidocrocite just anterior to this; and apatite throughout the core and anterior regions of the cusp. Biomineralization in these teeth is a matrix-mediated process, in which the minerals are deposited around fibers, with the different biominerals described as occupying architecturally discrete compartments. In this study, a range of scanning electron microscopes was utilized to undertake a detailed in situ investigation of the fine structure of the major lateral teeth. The arrangement of the organic and biomineral components of the tooth is similar throughout the three zones, having no discrete borders between them, and with crystallites of each mineral phase extending into the adjacent mineral zone. Along the posterior surface of the tooth, the organic fibers are arranged in a series of fine parallel lines, but just within the periphery their appearance takes on a "fish scale"-like pattern, reflective of the cross section of a series of units that are overlaid, and offset from each other, in adjacent rows. The units are approximately 2 microm wide and 0.6 microm thick and comprise biomineral plates separated by organic fibers. Two types of subunits make up each "fish scale": one is elongate and curved and forms a trough, in which the other, rod-like unit, is nestled. Adjacent rod and trough units are aligned into large sheets that define the fracture plane of the tooth. The alignment of the plates of rod-trough units is complex and exhibits extreme spatial variation within the tooth cusp. Close to the posterior surface the plates are essentially horizontal and lie in a lateromedial plane, while anteriorly they are almost vertical and lie in the posteroanterior plane. An understanding of the fine structure of the mineralized teeth of chitons, and of the relationship between the organic and mineral components, provides a new insight into biomineralization mechanisms and controls.

Contribution of Raman spectroscopy to identification of biominerals present in teeth of Acanthopleura rehderi, Acanthopleura curtisiana, and Onithochiton quercinus.

Raman spectroscopic investigations of the major lateral teeth of the chitons Acanthopleura rehderi and Acanthopleura curtisiana indicate that, in addition to the magnetite of the cutting surface and a carbonated hydroxyapatite in the central tooth core, these species deposit limonite in place of the lepidocrocite reported for other members of the genus Acanthopleura. A comparison of the spectra from these species with those of Onithochiton quercinus, which also deposits limonite, indicates that the current assignment of these species to Acanthopleura may not be appropriate. Biomineralization of the major lateral teeth may be a useful parameter to include in the taxonomic classification of chiton species.

A new biomineral identified in the cores of teeth from the chiton Plaxiphora albida.

The hydrated iron(III) oxide limonite is reported for the first time as a biomineral. In situ laser Raman spectra of the tooth cores from major lateral teeth of the chiton Plaxiphora albida are compared with those of synthetic and mineral iron phosphates and iron oxides. Raman spectra measured on iron phosphate and iron oxide standard materials are shown to be easily distinguishable from one another. The central tooth cores of mature P. albida teeth do not show any evidence for the presence of a separate iron phosphate mineral. Rather, in each tooth a narrow band of the hydrated iron(III) oxide limonite is shown to separate the magnetite of the tooth surface from a central core region comprising both lepidocrocite and limonite. The high concentration of phosphorus in P. albida tooth cores, previously observed by energy dispersive spectroscopy, is not associated with a separate iron phosphate mineral, indicating that this element may be adsorbed onto the surface of the iron oxide minerals present. The failure to detect a separate iron(III) phosphate is discussed with reference to other chiton species that display high levels of iron and phosphorus in the cores of their mature major lateral teeth.