Gamification for health promotion: systematic review of behaviour change techniques in smartphone apps.

OBJECTIVE: Smartphone games that aim to alter health behaviours are common, but there is uncertainty about how to achieve this. We systematically reviewed health apps containing gaming elements analysing their embedded behaviour change techniques. METHODS: Two trained researchers independently coded apps for behaviour change techniques using a standard taxonomy. We explored associations with user ratings and price. DATA SOURCES: We screened the National Health Service (NHS) Health Apps Library and all top-rated medical, health and wellness and health and fitness apps (defined by Apple and Google Play stores based on revenue and downloads). We included free and paid English language apps using 'gamification' (rewards, prizes, avatars, badges, leaderboards, competitions, levelling-up or health-related challenges). We excluded apps targeting health professionals. RESULTS: 64 of 1680 (4%) health apps included gamification and met inclusion criteria; only 3 of these were in the NHS Library. Behaviour change categories used were: feedback and monitoring (n=60, 94% of apps), reward and threat (n=52, 81%), and goals and planning (n=52, 81%). Individual techniques were: self-monitoring of behaviour (n=55, 86%), non-specific reward (n=49, 82%), social support unspecified (n=48, 75%), non-specific incentive (n=49, 82%) and focus on past success (n=47, 73%). Median number of techniques per app was 14 (range: 5-22). Common combinations were: goal setting, self-monitoring, non-specific reward and non-specific incentive (n=35, 55%); goal setting, self-monitoring and focus on past success (n=33, 52%). There was no correlation between number of techniques and user ratings (p=0.07; rs=0.23) or price (p=0.45; rs=0.10). CONCLUSIONS: Few health apps currently employ gamification and there is a wide variation in the use of behaviour change techniques, which may limit potential to improve health outcomes. We found no correlation between user rating (a possible proxy for health benefits) and game content or price. Further research is required to evaluate effective behaviour change techniques and to assess clinical outcomes. TRIAL REGISTRATION NUMBER: CRD42015029841.

Aberrant response to commensal Bacteroides thetaiotaomicron in Crohn's disease: an ex vivo human organ culture study.

BACKGROUND: Human ex vivo evidence indicating that an inappropriate immune response(s) to nonpathogenic bacteria contributes to disease pathogenesis in pediatric Crohn's disease (CD) is limited. The aim of the present study was to compare and contrast the early innate immune response of pediatric "healthy" versus CD mucosa to pathogenic, probiotic, and commensal bacteria. METHODS: "Healthy control" and CD pediatric mucosal biopsies (terminal ileum and transverse colon) were cocultured for 8 hours with E. coli O42, Lactobacillus GG (LGG), Bacteroidesthetaiotaomicron (B. theta), or stimulated with interleukin (IL)-1ß (positive control). Matched nonstimulated biopsies served as experimental controls. IL-8 was the immune marker of choice. IL-8 mRNA and protein levels were quantified by quantitative polymerase chain reaction and sandwich enzyme-linked immunosorbent assay, respectively. RESULTS: IL-8 secretion was observed when control, ileal biopsies were exposed to pathogenic O42 and probiotic LGG, with no response noted to commensal B. theta. In comparison, Crohn's ileal biopsies showed impaired ability to induce IL-8 in response to O42 and LGG. Control colonic tissue showed a limited response to O42 or B. theta and LGG significantly reduced IL-8 secretion. Unlike control tissue, however, Crohn's ileal and colonic tissue did respond to B. theta, with more enhanced expression in the colon. CONCLUSIONS: We provide the first ex vivo data to support the notion that aberrant mucosal recognition of commensal bacteria may contribute to pediatric CD. While IL-8 responses to O42 and LGG varied with disease status and anatomical location, B. theta consistently induced significant IL-8 both in ileal and colonic CD tissue, which was not seen in control, healthy tissue.

Biofilm form and function: carbon availability affects biofilm architecture, metabolic activity and planktonic cell yield.

AIMS: To investigate carbon transformation by biofilms and changes in biofilm architecture, metabolic activity and planktonic cell yield in response to fluctuating carbon availability. METHODS AND RESULTS: Pseudomonas sp. biofilms were cultured under alternating carbon-replete and carbon-limited conditions. A shift to medium without added carbon led to a 90% decrease in biofilm respiration rate and a 40% reduction in planktonic cell yield within 1 h. Attached cell division and progeny release were shown to contribute to planktonic cell numbers during carbon limitation. Development of a significantly enlarged biofilm surface area during carbon limitation facilitated a rapid increase in whole-biofilm metabolic activity, cell yield and biomass upon the re-introduction of carbon after 8 days of limitation. The cumulative number of planktonic cells (>10(10) CFU) released from the biofilm during the cultivation period contained only 1·0% of the total carbon available to the biofilm, with 6·5% of the carbon retained in the biofilm and 54% mineralized to CO(2) . CONCLUSIONS: Biofilm-derived planktonic cell yield is a proliferation mechanism. The rapid response of biofilms to environmental perturbations facilitates the optimal utilization of resources to promote both proliferation and survival. Biofilms function as efficient catalysts for environmental carbon transformation and mineralization. SIGNIFICANCE AND IMPACT OF THE STUDY: A greater understanding of the relationship between biofilm form and function can inform strategies intended to control and/or promote biofilm formation.

Anaerobic treatability and biogas production potential of selected in-mill streams.

Biochemical methane potential assays (BMP assays) were performed to study the potential of anaerobic treatment of in-mill wastewaters. The assay results indicated that condensate and the BCTMP effluent, which are currently treated with the anaerobic internal circulation reactors, were the best streams for anaerobic treatment because of their relatively high degradability (>80%) and initial rates of biogas production. The softwood dewatering process stream was the worst with the lowest degradability (~30%). The hardwood stream was more degradable than the softwood stream from the same process. Biogas production was found to be additive and predictable in blended samples. In addition, degradability was found to be negatively correlated to the concentration of dehydroabietic acid and tannin-lignin compounds. The anaerobic treatment of the suitable streams has great potential value with significantly reduced sludge production and energy savings.

Variations in expression of carbon isotope fractionation of chlorinated ethenes during biologically enhanced PCE dissolution close to a source zone.

The stable carbon isotope values of tetrachloroethene (PCE) and its degradation products were monitored during studies of biologically enhanced dissolution of PCE dense nonaqueous phase liquid (DNAPL) to determine the effect of PCE dissolution on observed isotope values. The degradation of PCE was monitored in a 2-dimensional model aquifer and in a pilot test cell (PTC) at Dover Air Force Base, both with emplaced PCE DNAPL sources. Within the plume down gradient from the source, the isotopic fractionation of dissolved PCE and its degradation products were consistent with those observed in biodegradation laboratory studies. However, close to the source zone significant shifts in the isotope values of dissolved PCE were not observed in either the model aquifer or PTC due to the constant input of newly dissolved, non fractionated PCE, and the small isotopic fractionation associated with PCE reductive dechlorination by the mixed microbial culture used. Therefore the identification of reductive dechlorination in the presence of PCE DNAPL was based upon the appearance of daughter products and the isotope values of those daughter products. An isotope model was developed to simulate isotope values of PCE during the dissolution and degradation of PCE adjacent to a DNAPL source zone. With the exception of very high degradation rate constants (>1/day) stable carbon isotope values of PCE estimated by the model remained within error of the isotope value of the PCE DNAPL, consistent with measured isotope values in the model aquifer and in the PTC.

In vitro activity of fusidic acid and mupirocin against coagulase-positive staphylococci from pets.

OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) and multiresistant Staphylococcus pseudintermedius (MRSP) have emerged as important pathogens in animal infections. Associated therapeutic problems and the zoonotic potential of staphylococci have renewed interest in topical antibiotics for treatment and carrier decolonization. Fusidic acid and mupirocin are used topically in humans and animals but resistant strains isolated from people are increasing. This study investigates the in vitro activity of fusidic acid and mupirocin against coagulase-positive staphylococci from pets. METHODS: A collection of 287 staphylococci was examined, comprising 102 MRSA, 102 methicillin-susceptible S. aureus, 71 S. pseudintermedius and 12 MRSP from canine and feline infections and carrier sites isolated in the UK and Germany. MICs were determined by the agar dilution method according to CLSI (formerly NCCLS) standards. RESULTS: The majority (89.7%) of all MICs were

Engineered heparins: novel beta-secretase inhibitors as potential Alzheimer's disease therapeutics.

BACKGROUND: Cleavage of beta-amyloid precursor protein (APP) by the protease beta-secretase (BACE1) is a key step in beta-amyloid peptide processing. We have described a novel role for heparan sulphate polysaccharides in Alzheimer's disease pathology as naturally occurring inhibitors of beta-secretase, suggesting new avenues for discovery of novel drugs for Alzheimer's disease based on heparins. OBJECTIVE: To evaluate engineered heparin analogues as novel beta-secretase inhibitors in vitro, including modifications to increase bioavailability. METHODS: We tested a number of selectively desulphated and chemically modified heparins for their ability to inhibit BACE1 and other proteases in vitro using APP fluorescent resonance energy transfer peptide substrates RESULTS: Several lead compounds have been identified that are effective beta-secretase inhibitors, but have negligible activity as anticoagulants or as inhibitors of other aspartyl proteases structurally related to beta-secretase. In addition, the compounds studied also give some insight into the structural interaction between beta-secretase and heparin, indicating that the structure of the polysaccharide is much more important than charge. CONCLUSION: We have demonstrated that modifications to increase bioavailability of chemically modified heparins have little effect on their efficacy as beta-secretase inhibitors. Therefore, these heparins show promise for development as a novel class of pharmaceuticals that target the underlying pathology of Alzheimer's disease. We have also found further evidence that it is the structure of the polysaccharide that is important for the interaction with beta-secretase, not simply the level of sulphation or charge.

Long-term respiratory support in children with giant omphalocele.

Omphalocele is one of the most common fetal abdominal wall defects. When this defect is of giant size, significant respiratory compromise may occur and impact on prognosis. We present three infants with giant omphalocele, highlighting the potential need for ongoing ventilatory support after the neonatal period in children born with this condition. The three cases had very different outcomes but all had significant ventilatory insufficiency and required substantial respiratory support at least into the second year of life. The possibility of a requirement for long-term ventilatory support should be discussed with families at antenatal diagnosis. A conservative surgical approach, together with early monitoring for hypoventilation and screening for the development of pulmonary hypertension is indicated for these children to limit morbidity. We suggest early tertiary respiratory input and advocate for a specific case manager to oversee the regional care of these children.

Dechlorination after thermal treatment of a TCE-contaminated aquifer: laboratory experiments.

A microcosm study was conducted to evaluate dechlorination of trichloroethene (TCE) to ethene and survival of dechlorinating bacteria after a thermal treatment in order to explore the potential for post-thermal bioremediation. Unamended microcosms containing groundwater and aquifer material from a contaminated site dechlorinated TCE to cis-1,2-dichloroethene (cDCE), while lactate-amended microcosms dechlorinated TCE to cDCE or ethene. A thermal treatment was simulated by heating a sub-set of microcosms to 100 degrees C for 10d followed by cooling to 10 degrees C over 150 d. The heated microcosms demonstrated no dechlorination when unamended. However, when amended with lactate, cDCE was produced in 2 out of 6 microcosms within 300 d after heating. Dechlorination of TCE to cDCE thus occurred in fewer heated (2 out of 12) than unheated (10 out of 12) microcosms. In unheated microcosms, the presence of dechlorinating microorganisms, including Dehalococcoides, was confirmed using nested PCR of 16S rRNA genes. Dechlorinating microorganisms were detected in fewer microcosms after heating, and Dehalococcoides were not detected in any microcosms after heating. Dechlorination may therefore be limited after a thermal treatment in areas that have been heated to 100 degrees C. Thus, inflow of groundwater containing dechlorinating microorganisms and/or bioaugmention may be needed for anaerobic dechlorination to occur after a thermal treatment.

Effect of phosphorus limitation on microbial floc structure and gene expression in activated sludge.

The effect of limiting phosphorus (P) in activated sludge was investigated in laboratory-scale sequencing batch reactors (SBRs). Correlative microscopy revealed that P-limitation (COD:N:P = 100:5:0.05) leads to morphological changes in floc structure and the composition of extracellular polymeric substances (EPS). This was found to be accompanied by expression of quorum-sensing in an acyl homoserine lactone bioassay. Differential gene expression in relation to P-limitation was examined in a global profile using the Affymetrix Escherichia coli antisense genomic microarray. Three separate experiments were conducted where the impact of P-limitation was examined under batch conditions and in SBRs at stable operating conditions and within 3-7 days following a down-shift in P. Significant changes in open reading frames (ORF) and intergenic regions based on the E. coli microarray were observed. Several genes associated with cell structure, including slt, wbbH, fimH, amB, rfaJ and slp were found to be expressed. Quorum regulated genes were also found to be expressed including psiF which is known to be induced by P-starvation (92% confidence level; 1.45 log ratio).

Nitric oxide levels and ciliary beat frequency in indigenous New Zealand children.

New Zealand children's morbidity from respiratory disease is high. This study examines whether subclinical ciliary abnormalities underlie the increased prevalence of respiratory disease in indigenous New Zealand children. A prospective study enrolled a group of healthy children who were screened for respiratory disease by questionnaire and lung function. Skin-prick tests were performed to control for atopy. Exhaled and nasal NO was measured online by a single-breath technique using chemiluminescence. Ciliary specimens were obtained by nasal brushings for assessment of structure and function. The ciliary beat frequency (CBF) (median CBF, 12.5 Hz; range, 10.4-16.8 Hz) and NO values (median exhaled NO, 5.6 ppb; range, 2.3-87.7 ppb; median nasal NO, 403 ppb; range, 34-1,120 ppb) for healthy New Zealand European (n=58), Pacific Island (n=61), and Maori (n=16) children were comparable with levels reported internationally. No ethnic differences in NO, atopy, or CBF were demonstrated. Despite an apparently normal ciliary beat, the percentage of ciliary structural defects was 3 times higher than reported controls (9%; range, 3.6-31.3%), with no difference across ethnic groups. In conclusion, it is unlikely that subclinical ciliary abnormalities underlie the increased prevalence of respiratory disease in indigenous New Zealand children. The high percentage of secondary ciliary defects suggests ongoing environmental or infective damage.

Paediatric home ventilatory support: the Auckland experience.

OBJECTIVES: To examine the trend over time, describe the disease categories treated, intervention success and outcomes of the children treated at home with continuous positive airway pressure (CPAP), non-invasive ventilation (NIV) and ventilation via tracheostomy (invasive ventilatory support, IVS) by the Respiratory Service at the Starship Children's Hospital in Auckland. METHODS: A retrospective review was undertaken of the Respiratory Service records from November 1991 to February 2004. RESULTS: Home CPAP, NIV or IVS was initiated in 160 children (89 boys, median age 6 years) in the study period. Sixty-nine (46 boys) remain on support and are still actively managed by the Starship Respiratory Service, of whom 46% live outside the Greater Auckland Region. Despite 42% of children being less than 5 years of age at initiation of therapy, institution of support failed in only 11%. The majority received treatment by non-invasive mask interface (68% (n = 108) CPAP, 29% (n = 47) NIV), with only 3% (n = 5) supported via tracheostomy. The numbers and complexity of support rose over the 12 years. Respiratory support was discontinued in 57% of cases, after a median of 12.5 months (range 3-52 months); in two-thirds, support was no longer required due to an improvement in the medical condition. The most common indication for support in current patients is respiratory parenchymal or airway disease followed by neuromuscular disease. Obesity is not a common indication. CONCLUSION: This review documents the increasing trend in children receiving respiratory support at home. Future planning and resources are needed to address this growing need.

HRCT lung abnormalities are not a surrogate for exercise limitation in bronchiectasis.

In paediatric bronchiectasis, there has been limited work on the relationship between disease severity as assessed by exercise limitation and high resolution computed tomography (HRCT). An observational study was performed on 36 children who completed a questionnaire, physical examination, spirometry and sputum analysis, followed by a low dose of radiation protocol chest computed tomography (CT) scan and cycle ergometry incremental exercise test. A modified Bhalla score was used to score the HRCT abnormalities. The exercise variables used to assess functional status were heart rate, oxygen consumption, oxygen saturations and time of exercise. The results were compared with established normal paediatric values. The median (range) age of the children was 13 yrs (10.6-17.1). Age, sex, height, weight or pubertal status were equally distributed between the children with cystic fibrosis (CF) or non-CF bronchiectasis. The children with non-CF bronchiectasis had a lower median forced expiratory volume in one second % predicted than the children with CF (69% versus 76%, respectively). The distribution of lung disease differed between the two groups. The children with CF bronchiectasis had predominantly right upper lobe disease, and scored higher for the presence and extent of bronchiectasis. Otherwise, there was no statistical difference in the overall CT score or the individual CT parameters between the groups. There was evidence of exercise limitation in both CF and non-CF bronchiectasis compared to normal children. No consistent relationships were identified between the lung function parameters, HRCT findings or exercise parameters in either disease group. In this study, high resolution computed tomography features were not found to be markers of exercise capacity. As spirometry, high resolution computed tomography features and exercise testing give different information in children with cystic fibrosis and non-cystic fibrosis bronchiectasis, the current authors suggest all three may be required for the comprehensive assessment of respiratory status.

Sending children home on tracheostomy dependent ventilation: pitfalls and outcomes.

In spite of the consistency of the primary discharge coordinator in our practice and attempts to streamline the process, the obstacles to discharge highlighted five years ago remain frustratingly similar. The children in this survey spent an average of 9.6 months extra time in hospital awaiting discharge at considerable cost to the local commissioning teams, quite apart from the emotional cost to the child and stress for the whole family. We hope in future years this review will enable health practitioners and local health providers to anticipate the hurdles, address the problems early, and expedite the process of discharging home children who are dependent on long term ventilation via tracheostomy.

Retrospective review of children presenting with non cystic fibrosis bronchiectasis: HRCT features and clinical relationships.

Non cystic fibrosis (CF) bronchiectasis in children presents with a spectrum of disease severity. Our aims were to document the extent and severity of disease in children with non-CF bronchiectasis, to review the inter- and intraobserver agreement for the high-resolution computed tomography (HRCT) features examined, and to assess correlations between HRCT features and clinical measures of severity. We performed a retrospective review of 56 children from the Starship Children's Hospital. HRCT scans were scored by a modified Bhalla system, and the chest X-rays using the Brasfield score. Scores were correlated with demographics, number of hospitalizations, disease duration, pulmonary function, clinical examination, and chronic sputum infection. The bronchiectasis seen was widespread and severe, particularly in Maori and Pacific Island children. The kappa coefficient for intraobserver agreement was better than that for interobserver agreement. Comparisons between HRCT scan and lung function parameters showed that the strongest relationships were between forced expiratory volume in 1 sec (FEV(1)) and forced expiratory flow between 25-75% of forced vital capacity (FEF(25-75)) with the extent of bronchiectasis, bronchial wall thickening, and air trapping. Children with digital clubbing and chest deformity showed significantly higher scores for extent of bronchiectasis, bronchial wall dilatation and thickness, and overall computed tomography (CT) score. No relationship was demonstrated between chronic sputum infection and CT score. The HRCT score demonstrated a stronger correlation between the extent and severity of bronchiectasis, and spirometry values, than the chest X-ray score. In conclusion, pediatric non-CF bronchiectasis in Auckland is extensive and severe. The good intraobserver ratings mean that consistency of scoring is possible on repeated scans. This study cannot comment on the relationships of CT and less severe disease.

Paediatric bronchiectasis in the twenty-first century: experience of a tertiary children's hospital in New Zealand.

OBJECTIVE: Despite its decline in developed countries, bronchiectasis appeared to be a common diagnosis in Auckland, New Zealand children. The aims of this study were: to document the number of children in Auckland with bronchiectasis, their severity, clinical characteristics and possible aetiologies; to assess whether there was a relationship between ethnicity and poverty; and to estimate a crude bronchiectasis prevalence rate for New Zealand. METHODS: A retrospective review of the case histories of all children attending a tertiary children's hospital in Auckland with bronchiectasis diagnosed by high-resolution chest computed tomography (CT) scan, during the period 1998-2000 was undertaken. Data collected included patient demographics, number of hospitalizations pre- and post-diagnosis, lung function tests, radiology and investigations. The New Zealand deprivation 1996 index was applied to the data to obtain a measure of socio-economic status. RESULTS: Bronchiectasis was found to be common, with an estimated prevalence of approximately one in 6000 in the Auckland paediatric population. It was disproportionately more common in the Pacific Island and Maori children. In Pacific Island children, bronchiectasis not caused by cystic fibrosis was nearly twice as common in the general population than cystic fibrosis. Socio-economic deprivation and low immunization rates may be significant contributing factors. The bronchiectasis seen was extensive. Ninety-three percent had bilateral disease and 64% had involvement of four or more lobes on chest CT scan. A wide range of comorbidities and underlying aetiologies were evident. CONCLUSIONS: Paediatric bronchiectasis in Auckland, New Zealand, is common but underresourced. Only the most severe cases are being recognized, providing a significant challenge for paediatric health professionals.

Variability in carbon isotopic fractionation during biodegradation of chlorinated ethenes: implications for field applications.

Stable carbon isotopic analysis has the potential to assess biodegradation of chlorinated ethenes. Significant isotopic shifts, which can be described by Rayleigh enrichment factors, have been observed for the biodegradation of trichloroethlyene (TCE), cis-dichloroethylene (cDCE), and vinyl chloride (VC). However, until this time, no systematic investigation of isotopic fractionation during perchloroethylene (PCE) degradation has been undertaken. In addition, there has been no comparison of isotopic fractionation by different microbial consortia, nor has there been a comparison of isotopic fractionation by consortia generated from the same source, but growing under different conditions. This study characterized carbon isotopic fractionation during reductive dechlorination of the chlorinated ethenes, PCE in particular, for microbial consortia from two different sources growing under different environmental conditions in order to assess the extent to which different microbial consortia result in different fractionation factors. Rayleigh enrichment factors of -13.8@1000, -20.4@1000, and -22.4@1000 were observed for TCE, cDCE, and VC, respectively, for dechlorination by the KB-1 consortium. In contrast, isotopic fractionation during reductive dechlorination of perchloroethylene (PCE) could not always be approximated by a Rayleigh model. Dechlorination by one consortium followed Rayleigh behavior (epsilon = -5.2), while a systematic change in the enrichment factor was observed over the course of PCE degradation by two other consortia. Comparison of all reported enrichment factors for reductive dechlorination of the chlorinated ethenes shows significant variation between experiments. Despite this variability, these results demonstrate that carbon isotopic analysis can provide qualitative evidence of the occurrence and relative extent of microbial reductive dechlorination of the chlorinated ethenes.

The effects of sequential combined oral 17beta-estradiol norethisterone acetate on insulin sensitivity and body composition in healthy postmenopausal women: a randomized single blind placebo-controlled study.

OBJECTIVE: The androgenic effect of progestogen, necessary in early postmenopausal hormone replacement therapy (HRT), may adversely affect insulin sensitivity as well as body fat distribution and thereby increase the cardiovascular risk profile. The impact of HRT with sequential combined oral 17beta-estradiol and norethisterone acetate on insulin sensitivity and body composition in early menopause has not been studied. DESIGN: A randomized single blind placebo-controlled 6-month study of sequential combined 17beta-estradiol norethisterone acetate on insulin sensitivity and body composition was carried out. Thirty fit healthy postmenopausal women were enrolled and completed this 6-month study. Body composition was measured by dual-energy x-ray absorptiometry scanning, and insulin sensitivity was measured using the euglycemic hyperinsulinemic clamp. Studies were undertaken at baseline and after 6 months of therapy. The studies were performed during the estrogen-only phase of therapy. RESULTS: All women demonstrated a degree of decreased insulin sensitivity that was not modified by 6 months of hormone replacement therapy. Body composition remained unchanged over 6 months. There was no alteration in total body fat or the distribution of body fat. The percentage of central abdominal fat (android) was not altered. CONCLUSION: Six months of HRT with sequential combined oral 17beta-estradiol norethisterone acetate does not have an adverse effect on insulin sensitivity and does not promote an increase in weight or the more android distribution of body fat, which could contribute to the increased cardiovascular risk profile that is evident in postmenopausal women.

Anaerobic toluene activation by benzylsuccinate synthase in a highly enriched methanogenic culture.

Permeabilized cells of a highly enriched, toluene-mineralizing, methanogenic culture catalyzed the addition of toluene to fumarate to form benzylsuccinate under anaerobic conditions. The specific in vitro rate of benzylsuccinate formation was >85% of the specific in vivo rate of toluene consumption. This is the first report of benzylsuccinate synthase activity in a methanogenic culture; the activity has previously been reported to occur in denitrifying, sulfate-reducing, and anoxygenic phototrophic bacteria.

A case of vaccine-associated paralytic poliomyelitis.

Vaccine-associated paralytic poliomyelitis (VAPP) is a very rare complication of oral polio vaccine (OPV), seen predominantly with first exposure to OPV. Reversion of vaccine strain poliovirus to a more neurovirulent strain of the virus is thought to be necessary for paralytic disease to occur. Vaccine-associated poliomyelitis can occur in either recipients of the vaccine or in susceptible contacts. We describe an episode of VAPP in an infant in whom paralysis became evident at age 124 days, 14 days after administration of the second dose of OPV vaccine. The second dose of diphtheria-tetanus-pertussis- Haemophilus (DTPH) type-b vaccine had been given at the time of OPV administration, and the hepatitis B vaccine had been administered in the opposite leg. Paralysis was localized to the limb in which the DTPH had been injected.