Developing and validating a new national remote health advice syndromic surveillance system in England.

Background: Public Health England (PHE) coordinates a suite of real-time national syndromic surveillance systems monitoring general practice, emergency department and remote health advice data. We describe the development and informal evaluation of a new syndromic surveillance system using NHS 111 remote health advice data. Methods: NHS 111 syndromic indicators were monitored daily at national and local level. Statistical models were applied to daily data to identify significant exceedances; statistical baselines were developed for each syndrome and area using a multi-level hierarchical mixed effects model. Results: Between November 2013 and October 2014, there were on average 19 095 NHS 111 calls each weekday and 43 084 each weekend day in the PHE dataset. There was a predominance of females using the service (57%); highest percentage of calls received was in the age group 1-4 years (14%). This system was used to monitor respiratory and gastrointestinal infections over the winter of 2013-14, the potential public health impact of severe flooding across parts of southern England and poor air quality episodes across England in April 2014. Conclusions: This new system complements and supplements the existing PHE syndromic surveillance systems and is now integrated into the routine daily processes that form this national syndromic surveillance service.

Outcomes research: contemporary issues and historical significance for nurse practitioners.

Outcomes research is not new to the discipline of nursing. However, the driving forces of today's health care environment are resulting in increased emphasis on the study of outcomes. This article presents an overview of the scope of outcomes research, including a historical perspective and contemporary issues. Outcomes research provides an opportunity to demonstrate the effectiveness of nurse practitioner practice.

Rh18 and hrS blood groups and antibodies.

Anti-hrS, also known as the Shabalala antibody, is unlikely to be found in unabsorbed human serum. The term 'anti-hrS, was devised by Shapiro in 1960 to describe the antibodies remaining in the absorbed serum after anti-Rh18 had been absorbed with R2R2 red cells. R2R2-absorbed anti-Rh18 (anti-hrS), although an interesting research tool, is therefore clinically irrelevant. Unabsorbed anti-Rh18, on the other hand, is a clinically significant antibody. It is compatible not only with Rh-'deleted' and Rhnull red cells, as described by Shapiro, but is also compatible with the red cells of numbers of Southern African Blacks and Coloureds (mixed race) who have Ro, Rou or R2r phenotypes. Anti-Rh18 causes haemolytic disease of the newborn and, when uncontaminated with other antibodies, is a further reagent for resolving Rh grouping problems.

The P1H antigen and antibody.

P1H. a newly discovered compound antigen associated with both the ABO and P systems, occurs in approximately percent of Natal (South African) blacks. The compound antigen, is evident only when the red cells have exceptionally strong expression of both and H antigens, and it is apparently a dominant character. The antigen is thought to originate by steric rearrangement in the molecule, or to be the product of competition between pl and H gene transferases for the available paragloboside The corresponding antibody, anti-P1H, has been made by both P1 and P2 people and is a weak cold agglutinin It is not adsorbed by red cell, carrying either strongly expressed P1 or H antigens but is adsorbed by and eluted from P1H+ red cells sensitized by anti- P1H. The antibody is, inhibited by P1 but not by H. Lewis, or Sda substances.

STEM, a new low-frequency Rh antigen associated with the e-variant phenotypes hrS-(Rh: -18, -19) and hrB-(Rh: -31, -34).

The new low-frequency antigen STEM was identified when a Cape coloured woman with an unknown antibody in her plasma (which agglutinated the red cells of her husband and a minority of other individuals) gave birth to a baby suffering mildly from haemolytic disease of the new-born. Most, but not all, examples of anti-STEM distinguish different strengths of STEM antigen on the red cells of different people; the different strengths are inherited. Family studies established that STEM was inherited as a Mendelian dominant character. STEM subdivides hrS-(Rh: -18, -19) and hrB- (Rh: -31, -34) red cells into two types: STEM+ and STEM-. The manually calculated lod score for STEM being associated with the Rh system is 3.91 and LIPED calculated lod score 4.35. The International Society of Blood Transfusion has allocated STEM the Rh number 49.

Rh33 in two of three German siblings with D+ C+ c+ E- e+ red cells.

The proposita in a German family of three siblings has D+ C+ c+ E- e+ f+ Rh: -17,19,33,34 red cells with weak C, e, f, Rh19, and Rh34 and stronger-than-usual Rh33 expression. One sibling has D+ C+ c+ E- e+ f+ Rh:17,19,33,34 red cells with weak f and ordinary-strength Rh33, and the other sibling has D+ C+ c+ E- e+ f+ Rh:17,19,-33,34 red cells. In the absence of any further family members, the proposita's unusual phenotype suggests that she has an RoHar haplotype and a "new" Rh haplotype, provisionally named R1Lisa, that encodes Rh33, normal-strength D, weak C, weak or nondemonstrable e, Rh19, and Rh34, but not Rh17. Her Rh:33 sibling may have R1 and RoHar and her Rh:-33 sibling R1 and r haplotypes.

D-- and Dc- gene complexes in the coloureds and blacks of Natal and the eastern Cape and blood group phenotype and gene frequency studies in the Natal coloured population.

Following the detection of apparent exclusions in the Rh system in two Coloured (mixed race) families during paternity testing, a rare D-- gene complex was identified in one family and two examples of an unusual gene complex producing weak e and very weak or non-demonstrable f antigen in the other. The latter, which almost certainly belong to the heterogeneous collection known as Dc-, were found when the Rh phenotypes expected to give f+, instead gave f- or f+W (weak positive) results and those expected to give f-, gave f+W results. Blood group phenotype and gene frequency studies showed that the Natal Coloured population contains a mixture of approximately 40% Black, 30% White and 30% Indian (Asian) genes. The phenotypes A1 high H, B high H, B low H, K+ and Kp(a+) associated with Caucasoids and the phenotypes Abantu, Dantu+, hrS- (Rh: -18,-19), hrB- (Rh: -31,-34) and Fy(a-b-) associated with Negroids were all represented. The DCe/Dc- frequency was 6.9% and the DcE/Dc- frequency 2.6%.

Serology and genetics of the red blood cell factor Rh34.

Rh34 antibodies were found to have a unique, previously only partly characterised, specificity within the Rh system. No evidence was seen that they were mixtures of hrB and Hr-like antibodies, or that hrB antibodies existed independently in the natural state. The term anti-hrB applied to Rh34 antibodies after they had been partially absorbed with R2R2 red cells. Four haplotypes not expressing Rh34 antigen were identified in the present study. The prefix * has been used to indicate them in this text. They were *r's (*dCces), *Ro (*Dce), *Rou (*D(uce)) and *R(od) (category III *Dce). Red cells with partially deleted or Rh(null) phenotypes were therefore not the sole red cells compatible with anti-Rh34. R2R2 red cells, which are known to carry weak Rh34 antigen, were incompatible. Twenty-two family and mother-child studies established that the Rh:-34 haplotypes were inherited as normal Mendelian dominant characters. Anti-Rh34 was capable of recognising RH 34 dosage and of excluding some men who had been wrongly accused in disputed paternity tests.

Wd(a+) red blood cells in two sisters of a Hei//om Khoisan family in Namibia.

Two sisters in a Hei//om family of the southern African Khoisan race in Namibia were found to have Wd(a+) red blood cells. Wda is a low-frequency antigen identified so far only in a European family in Canada and a family in Holland. The Wda gene may have had an independent origin in the Khoisan. Alternatively, the Hei//om population may have acquired it through miscegenation.

Anti-Gerbich antibodies and Gerbich-negative Dantu-positive red blood cells in a woman from South Africa.

Anti-Gerbich type anti-Ge3 antibodies were identified in the serum of a woman of mixed ethnic origin from Cape Town. The woman had type Ge:-2,-3 (Gerbich) red cells on which there was no evidence of weakened Kell antigens. Her red cells were also Dantu-positive.

Enhanced reaction with Vicia graminea lectin and exposed terminal N-acetyl-D-glucosaminyl residues on a sample of human red cells with Hb M-Hyde Park.

A sample of polyagglutinable red cells was obtained from a healthy individual (group O, N) possessing a hemoglobin (Hb) variant called Hb M-Hyde Park. The sialic acid content of the individual's red cells is 90 percent of normal, and his cells are agglutinated by monoclonal but not lectin anti-Tn, a panel of lectins specific for N-acetylgalactosamine (or galactose), and N-acetylglucosamine. Enhanced agglutination reactions were obtained with Vicia graminea, Ulex europaeus, and human anti-I and -i. Using various enzyme treatments and different methods of labeling cell surface components, two defective cell membrane sites have been identified: one associated with the O-linked oligosaccharides on sialoglycoproteins and the other associated with exposed N-acetylglucosaminyl residues located on membrane components of apparent molecular weights 88,000 to 130,000 and 46,000 to 73,000 (probably the Band 3 and Band 4.5 regions, respectively).

Haemoglobin M-Hyde Park associated with polyagglutinable red blood cells in a South African family.

Twelve of 35 members tested in a large ethnically-mixed South African family were found to have both haemoglobin M type Hyde Park and persistent polyagglutinable red blood cells. The characteristics of the polyagglutination have not been recorded previously. The cells of affected family members were not agglutinated by Arachis hypogea, Dolichos biflorus or Salvia sclarea, but were agglutinated weakly by Salvia horminum and BSII (GSII) and reacted strongly with Glycine soja and Sophora japonica lectins. BSI (GSI) lectin agglutinated the group A but not the group O cells. The N and MN cells were agglutinated more strongly than normal by Vicia graminea, other anti-N lectins and human anti-N but the M and MN cells reacted as expected with human anti-M. The name 'Hyde Park' is provisionally suggested for this type of polyagglutination, although it appears unlikely that the evidently complete association between the polyagglutination and the variant haemoglobin is the result of a single genetic mutation. More likely, the connection has a post-genetic origin, perhaps showing that bonds, possibly affected adversely by precocious senescence, normally occur between the haemoglobin and alpha-sialoglycoprotein molecules in red blood cells.

Zulu XX/XX dispermic chimaera from Natal with two populations of red blood cells and patchy skin pigmentation.

The chimaera is female and has two children. Her blood contains 99% group O, type AcP:BA, Pep-A:8-2 and 1% group A2B, type AcP:RA, Pep-A:1 red cells. H-, A- and B-transferase activities were demonstrated in her serum. The level of the H enzyme activity is low but is at the lower end of the normal range for group O persons. The levels of the A and B enzymes are also low but are higher than expected in a person with 1% A2B red cells in the blood. The levels of the A and B enzymes indicate that tissues other than the chimaera's haemopoietic tissue carry her genetically A2B cell line and are contributing the corresponding transferases to her plasma. Gross patchy skin pigmentation is present on the upper part of her body. The chimaera has evidently inherited two dissimilar germ nuclei from each parent.

Congenital dyserythropoietic anaemia (type II) presenting with haemosiderosis.

A 39-year-old female with type II congenital dyserythropoiesis presented with iron overload. The clinical and haematologic features were an anaemia of variable severity, splenomegaly, numerous bizarre and binucleate normoblasts in the bone marrow, with prominent submembranous cisternae in the late forms, a positive Ham's acid lysis test and aberrant expression of the I and i red cell antigens. The iron overload resulted from gross ineffective erythropoiesis, with accelerated plasma iron turnover and increased absorption aggravated by inappropriate replacement therapy for past episodes of anaemia.

Association of the human Lewis blood group Le(a-b-c-d-) with the failure of expression of alpha-3-L fucosyltransferase.

Two unrelated individuals are reported who lack alpha-3-L-fucosyltransferase activity in their serum and saliva. Both were blacks, one from the United States and the other from South Africa. No other of the tested members of their families lacked this enzyme. A survey of more than 2000 serum samples from both black and white South African blood donors, black United States donors and white United Kingdom donors failed to disclose another example of a serum deficient in alpha-3-L-fucosyltransferase activity. The two individuals lacking in alpha-3-L-fucosyltransferase activity both had the Lewis blood group phenotype Le(a-b-c-d-). No other persons with this phenotype have been reported. The absence of Lec activity in the two individuals who are deficient in alpha-3-L-fucosyltransferase is consistent with the interpretation that alpha-3-linked L-fucose is an essential part of the antigenic determinant recognised by the anti-Lec reagent used in this investigation.

Rhnull red cells and pregnancy.

The haemoglobin, haematocrit and osmotic fragility red cell values in a South African white woman with Rhnull cells and the corresponding haematological syndrome were shown to vary only minimally during her third pregnancy. This occurred in spite of the precautionary donation by her of two units of her blood at 20 and 27 weeks of pregnancy for storage in liquid nitrogen. Although there was fear to the contrary, the woman's infant was found at birth to be suffering only mildly from haemolytic disease of the newborn due to the anti-Rh29 antibodies present in her plasma.