Detection of Xanthomonas fragariae and presumptive detection of Xanthomonas arboricola pv. fragariae, from strawberry leaves, by real-time PCR.

Real-time (TaqMan) PCR assays were developed to detect the strawberry angular leaf spot pathogen Xanthomonas fragariae (Xf) and the strawberry bacterial blight pathogen Xanthomonas arboricola pv. fragariae (Xaf). The Xf PCR (Xf gyrB) was designed within regions of the gyraseB gene, unique to Xf, after generating gyraseB DNA sequence data from Xf and other closely related strains. The Xaf PCR (Xaf pep) was designed within regions of the pep prolyl endopeptidase gene that were unique to Xaf, after generating pep DNA sequence data from Xf and Xaf strains. The Xf gyrB PCR detected only Xf strains amongst a panel of 20 Xanthomonas-related spp. and pathovars. The Xaf pep PCR assay detected all Xaf strains tested plus two other (of three tested) X. arboricola pathovars. An existing genomic DNA extraction protocol was modified to facilitate detection of both pathogens to 10(3) cells per strawberry leaf disc.

The effects of tropospheric ozone on the species dynamics of calcareous grassland.

Although ozone has been shown to reduce the growth of individual species and to alter the composition of simple species mixtures, there is little understanding of its long-term effects on species dynamics and composition in real communities. Intact turfs of calcareous grassland were exposed to four different ozone regimes in open-top chambers over three consecutive summers. Treatments provided a mean seasonal AOT40 ranging from approximately zero to 15 ppm h. Cumulative ozone exposure was a significant factor in compositional change, but only explained 4.6% of the variation. The dominant grass species (Festuca rubra) showed a consistent decline in cover in the high ozone treatment over time and the forb Campanula rotundifolia was lost from all three ozone treatments. The frequency of some species (Galium verum and Plantago lanceolata) increased with ozone exposure. Long-term effects of ozone on species composition in chalk grassland may be a function of both the sensitivity of individual species and the response of the dominant species.

Transcriptional regulation of components of the type III secretion system and effectors in Pseudomonas syringae pv. phaseolicola.

Quantitative real-time polymerase chain reaction was used with specific TaqMan probes to examine transcription of selected hrp and effector genes in Pseudomonas syringae pv. phaseolicola strains 1448A (race 6) and 1449B (race 7). Transcripts examined were from genes encoding the regulators hrpR and hrpL, core structural components of the type III secretion system (TTSS) hrcC, hrcJ, hrcN, hrcU, and hrpA; the first open-reading frame of each hrp operon, including hrpF, hrpJ, hrpP, and hrpY, and also secreted effectors hrpZ, avrPphE, avrPphF, and virPphA. All genes were induced by incubation in a minimal medium and showed patterns of expression indicating regulation by HrpRS and HrpL. Basal mRNA levels and the timing of accumulation of transcripts after induction differed significantly, suggesting the operation of additional regulatory elements. However, no clear transcriptional hierarchy emerged to explain the ordered construction of the TTSS. Quantitative analysis confirmed that the rates and levels of transcript accumulation within the first 2 h after inoculation were considerably higher in planta than in vitro, and indicated that plant cell wall contact may enhance transcription of TTSS and effector genes in P. syringae pv. phaseolicola. The low-abundance hrcU mRNA had a half-life of 16.5 min, whereas other transcripts had half-lives between 3 and 8 min.

Dwarfism, rhizomelic limb shortness, and abnormal face: new short stature syndrome sharing some manifestations with Robinow syndrome.

We describe a child with short stature of prenatal onset, rhizomelic limb shortness affecting the upper limbs particularly, and an unusual face. She had frontal balding, mid-face hypoplasia, a small nose, macrostomia with down-turned corners of the mouth, gingival hypertrophy, and hypoplasia or absence of the clitoris. There was no gross modelling defect of the skeleton and the vertebral column was normal. Some of these manifestations overlap with those of Robinow syndrome.

Drug resistance in Campylobacter jejuni, C coli, and C lari isolated from humans in north west England and Wales, 1997.

AIMS: To test the sensitivity of strains of Campylobacter species isolated from humans in England and Wales against a range of antimicrobial agents for the purpose of monitoring therapeutic efficacy and as an epidemiological marker. METHODS: An agar dilution breakpoint technique was used to screen isolates against ampicillin, chloramphenicol, gentamicin, kanamycin, neomycin, tetracycline, nalidixic acid, ciprofloxacin, and erythromycin. Minimal inhibitory concentrations (MIC) were also determined for a sample of quinolone resistant strains. RESULTS: Approximately 50% of strains tested were resistant to at least one drug. Strains which were resistant to four or more of the drugs tested were classified as multiresistant; this occurred in 11.3% of C jejuni, 19.9% of C coli, and 63.6% of C lari. Resistance to erythromycin occurred in 1.0% of C jejuni and 12.8% of C coli. Resistance to quinolones occurred in 12% of strains, with a ciprofloxacin MIC of > 8 mg/l and a nalidixic acid MIC of > 256 mg/l; a further 4% of strains had intermediate resistance with a ciprofloxacin MIC of between 0.5 and 2 mg/l (fully sensitive strains, 0.25 mg/l or less) and a nalidixic acid MIC of between 32 and 64 mg/l (fully sensitive strains, 8 mg/l or less). CONCLUSIONS: Resistance to quinolones in campylobacters from human infection may relate to clinical overuse or use of fluoroquinolones in animal husbandry. Both veterinary and clinical use should be reconsidered and fluoroquinolone drugs used only as a treatment for serious infections requiring hospital admission. Erythromycin resistance is still rare in C jejuni but much more common in C coli.

Cost-efficacy comparison of inhaled fluticasone propionate and budesonide in the treatment of asthma.

BACKGROUND: The results of a recent meta-analysis comparing 2 inhaled corticosteroids, fluticasone propionate (FP) and budesonide, demonstrated that FP had an improved efficacy-to-safety ratio compared with budesonide. However, limited data are available on the relative economic benefits of these 2 regimens. OBJECTIVE: This pharmacoeconomic analysis used individual patient data from studies in the meta-analysis to compare the relative cost-efficacy of 2 asthma regimens from the perspective of a US third-party payer. METHODS: This analysis included all 7 studies in the meta-analysis that compared budesonide with FP dosed at approximately half the dose of budesonide and that included measurement of daily morning peak expiratory flow (PEF). RESULTS: The total daily per-person cost of asthma management was higher for patients treated with budesonide than with FP ($3.00 vs $2.25, respectively). Treatment with FP had greater cost-efficacy than treatment with budesonide, based on a range of outcome measures that included improvement in morning PEF, symptom-free days, and episode-free days. The daily cost per effectively treated patient (an increase in PEF of > or = 10%) was $5.62 with FP and $10.05 with budesonide. The cost per symptom-free day was $4.36 with FP, compared with $6.67 with budesonide. The cost per episode-free day was $5.60 with FP and $9.42 with budesonide. The pharmacoeconomic difference continued to favor FP as the criteria for success were made more stringent and the cost of budesonide was lowered. CONCLUSION: Based on data from the 7 randomized, controlled trials, treatment of asthma with FP was more effective and less expensive, using US health care assumptions and costs, than treatment with budesonide.

Cost-effectiveness of salmeterol/fluticasone propionate combination product 50/250 microg twice daily and budesonide 800 microg twice daily in the treatment of adults and adolescents with asthma. International Study Group.

Despite a good understanding of the disease and its treatments, asthma continues to place a large economic burden on healthcare systems. As such, it is important to consider the economic impact of alternative therapeutic options for the treatment of this condition to ensure that scarce resources are used in the most efficient manner possible. Thus, the aim of asthma management from an economic perspective is to reduce the burden of this disease through maximizing health gain with available resources. A prospective economic analysis was conducted as part of a multicentre, randomized, double-blind, comparative trial of salmeterol/fluticasone propionate combination product (SFC) 50/250 microg twice daily vs. budesonide (800 microg twice daily) in adults and adolescents with asthma who were symptomatic despite treatment with inhaled corticosteroids at doses of 800-1200 microg day(-1). Treatment effectiveness was measured in terms of successfully-treated weeks, defined as a > or =5% improvement in morning peak expiratory flow, episode-free days (a day without the need for rescue medication, no nocturnal awakening or adverse events) and symptom-free days. Cost-effectiveness analyses were performed using direct healthcare and drug costs, from the perspective of the Swedish healthcare system (1998 prices), with appropriate sensitivity analyses to test the robustness of the findings. Overall, SFC produced significantly higher (P<0.001) proportions of successfully-treated weeks, episode-free days and symptom-free days. Direct asthma management costs were similar between the two groups [SEK19.6 ($US2.4) for SFC vs. SEK18.5 (SUS2.2) for budesonide]. The cost per successfully-treated week was lower for SFC than for budesonide [SEK204 ($US24.8) vs. SEK300 ($US36.4) per week], as were the costs per episode-free day [SEK51.1 ($US6.2) vs. SEK75.1 ($US9.1) per day] and symptom-free day [SEK42.2 ($US5.1) vs. SEK53.0 ($US6.4) per day]. Incremental cost-effectiveness ratios showed that the additional costs to achieve additional benefits with SFC were minimal. Costs per additional successfully-treated week, symptom-free day and episode-free day with SFC were SEK31.6 ($US3.9), SEK9.2 ($US1.1) and SEK7.7 ($US0.9), respectively, relative to budesonide. Sensitivity analysis showed that the results were stable over a wide range of assumptions. The results suggest that SFC is a more cost-effective treatment than budesonide in the management of moderate to severe asthma.

The cost-effectiveness of inhaled fluticasone propionate and budesonide in the treatment of asthma in adults and children.

Inhaled corticosteroids form the mainstay of the treatment and management of asthma and the results of a meta-analysis comparing two of the most frequently prescribed inhaled corticosteroids, fluticasone propionate and budesonide, administered in a clinically equivalent 1:2 dose ratio to 1980 patients with asthma, demonstrated that fluticasone propionate had an improved efficacy:safety ratio. However, limited data are available on the relative economic benefits of fluticasone propionate and budesonide. The database for clinically relevant parameters, for which the efficacy:safety meta-analysis had demonstrated statistical significance between the two corticosteroids, was used for this pharmacoeconomic analysis. Treatment with fluticasone propionate was more cost-effective than budesonide with respect to improvement in morning peak expiratory flow rate, successfully treated weeks, symptom-free days, symptom-free 24 h and episode-free days. The costs of treatment for fluticasone propionate and budesonide were 7.78 Pounds per week and 12.33 Pounds per week, respectively. The main contributing factor to the higher costs of budesonide was the higher cost of health care contacts, which were 4.53 Pounds per week for budesonide and 0.57 Pounds per week for fluticasone propionate. The pharmacoeconomic difference increased in favour of fluticasone propionate as the criteria for success were made more stringent. These results demonstrate that, for asthma patients requiring modification of therapy treatment with fluticasone propionate is more effective and also cheaper, in terms of overall health-care costs, than treatment with budesonide.

Pharmacoeconomics in the new millennium. A pharmaceutical industry perspective.

The primary purpose of pharmacoeconomic research is to assist in making healthcare decisions. Rapid growth in the supply of pharmacoeconomic data over the past few years suggests that pharmacoeconomics can be of help in delivering good, cost-effective healthcare. Greater challenges in decision-making coupled with improvements in the techniques of pharmacoeconomic research point to a greater role for pharmacoeconomics into the new millennium. This in turn will have consequences for companies in the pharmaceutical industry. More successful access to markets and better commercialisation of products will be the rewards for those companies committing to pharmacoeconomics and to the broader goal of delivering value for money in healthcare.

Responses to a fourth dose of Haemophilus influenzae type B conjugate vaccine in early life.

OBJECTIVE: To describe the immune response of preterm infants, with a reduced response to primary Haemophilus influenzae type B (Hib) immunisation, to a fourth dose of Hib conjugate vaccine given in early life. DESIGN: Prospective observational study. SETTING: Five Wessex Neonatal Units. PATIENTS: Infants born at < 32 weeks and immunised with three doses of combined acellular pertussis-Hib vaccine, with a Hib IgG geometric mean concentration (GMC) < 1.0 microg/ml after these primary immunisations. INTERVENTIONS: An additional fourth dose of Hib conjugate vaccine given before 1 year of age. Blood taken to assess Hib IgG concentration and avidity after immunisation. MAIN OUTCOME MEASURES: Hib IgG GMC and avidity index. RESULTS: Ninety six infants (mean gestational age at birth 29.1 weeks) received a fourth dose of Hib at a mean age of 7.8 months. Hib IgG GMC after the primary immunisations was 0.17 microg/ml (95% confidence interval (CI) 0.14 to 0.20) rising to 4.68 microg/ml (95% CI 3.36 to 6.57) after the fourth dose (p < 0.0001). The IgG response to the fourth dose correlated positively with the response after the primary immunisations (p < 0.001). Hib IgG geometric mean avidity index (GMAI) after the primary immunisations was 30.87 (95% CI 20.40 to 46.73). This increased to 124.73 (95% CI 109.93 to 141.51) after the fourth dose (p < 0.0001). CONCLUSION: Preterm infants with very low IgG responses to Hib after primary immunisations with a combined acellular pertussis-Hib vaccine mount a good response to a fourth dose of Hib. This study suggests that all infants will benefit from a fourth dose of Hib, regardless of the age at which it is given.

Acellular pertussis vaccine given by accelerated schedule: response of preterm infants.

OBJECTIVE: To describe the immune response of preterm infants to a diphtheria/tetanus/three component acellular pertussis (DTaP) vaccine, under an accelerated schedule, and the effects of steroids on this response. To compare responses with those of term infants. DESIGN: Prospective observational study. SETTING: Five Wessex neonatal units; Hertfordshire immunisation clinics. PATIENTS: Infants born at < 32 weeks; term controls. INTERVENTIONS: DTaP-Haemophilus influenzae type b vaccine given at 2, 3, and 4 months. Blood taken to assess antibody responses to vaccines. MAIN OUTCOME MEASURES: IgG geometric mean concentrations (GMC) to vaccines. RESULTS: A total of 130 preterm (mean gestational age 29.1 weeks) and 54 term infants were recruited. After the third immunisation, preterm infants had similar GMCs to controls to diphtheria, tetanus, filamentous haemagglutinin (FHA), and pertactin (PRN), but a significantly lower GMC to pertussis toxin (PT). Responses to tetanus and PRN increased with age at the third immunisation, and those to tetanus, FHA, PRN, and PT increased with gestational age at birth. Response to tetanus correlated negatively with the number of doses of antenatal steroids received. There was no association between responses and postnatal steroids. CONCLUSION: When immunised with a combined acellular pertussis- H influenzae type b vaccine under an accelerated schedule, IgG GMC of preterm infants to PT was reduced. GMCs to tetanus, FHA, PRN, and PT increased with gestational age at birth, and GMCs to tetanus and PRN increased with age at the third immunisation. There is, however, no benefit in delaying immunisation. Anti-tetanus IgG decreased with increasing number of doses of antenatal steroids. There was no effect for postnatal steroids.

Nosocomial respiratory syncytial virus infection in neonatal units in the United Kingdom.

Nosocomial Respiratory Syncytial Virus infections are frequently reported and tend to be more severe, because of comorbidity, such reports, however, are frequently from a single centre. The incidence and outcomes of nosocomial Respiratory Syncytial Virus infection in UK neonatal units over a five year period were estimated by interrogating the Capse Health Care Knowledge Systems database, which contains anonymised details of 55% of UK hospital admissions. A total of 79,642 admissions commenced on the infants' date of birth and contained an ICD-10 code for low birth weight or immaturity. Thirty-seven of the 79,642 admissions also contained a Respiratory Syncytial Virus code. Two (5.4%) with Respiratory Syncytial Virus and 2,736 (3.4%) without Respiratory Syncytial Virus died. Survivors with Respiratory Syncytial Virus codes experienced significantly increased length of stay. In the extreme immaturity sub-group the length of stay was 117.5 days with Respiratory Syncytial Virus and 51.3 days without Respiratory Syncytial Virus (p = 0.0002). In the low birth weight or other preterm sub-group the length of stay with Respiratory Syncytial Virus was 69.2 and without Respiratory Syncytial Virus 14.7 days (p < 0.0001). The observed low rate for nosocomial Respiratory Syncytial Virus (0.46/1000 admissions) should be regarded as a minimum. The increased length of stay in infants with Respiratory Syncytial Virus infection emphasises that units should have guidelines to prevent and deal with Respiratory Syncytial Virus outbreaks.

DT5aP-Hib-IPV and MCC vaccines: preterm infants' response to accelerated immunisation.

AIMS: To describe the immune response of preterm infants to combined diphtheria/tetanus/5 component acellular pertussis-Haemophilus influenzae type b inactivated polio vaccine (DT5aP-Hib-IPV) and meningococcal serogroup C conjugate vaccine (MCC) under accelerated schedule. To compare results with term infants immunised with DT5aP-Hib-IPV and with historical data from preterm infants immunised with a DT3 component aP-Hib vaccine. METHODS: Prospective observational study in preterm infants born at <32 weeks gestation with comparison to contemporary cohort of term infants. DT5aP-Hib-IPV and MCC vaccines were given at 2, 3, and 4 months. RESULTS: Fifty preterm infants (mean gestational age 28.5 weeks) completed the study. After three doses of vaccines Hib polysaccharide IgG geometric mean concentration (GMC) was 1.21 microg/ml with 80% > or =0.15 microg/ml; MCC serum bactericidal assay geometric mean titre (GMT) was 1245 with 100% > or =8. All infants achieved protective titres to diphtheria, tetanus, and the three poliovirus types with > or =80% achieving protective rises in IgG against the five pertussis antigens. CONCLUSION: Preterm infants immunised with DT5aP-Hib-IPV and MCC vaccines show IgG responses to Hib and MCC greater than seen historically in both term and preterm infants with a DT3aP-Hib vaccine, and for pertussis antigens and poliovirus type 1 responses similar to that seen in term infants immunised with DT5aP-Hib-IPV. Responses to poliovirus types 2 and 3 are reduced, but all infants achieved protective titres.

Timing of immunisation of premature infants on the neonatal unit and after discharge to the community.

Premature infants discharged to the community are having their primary immunisations delayed and this delay increases with subsequent doses. The importance and safety of immunising premature infants should be stressed to parents, health visitors, and general practitioners.

Evidence for variable gene expression in a large inbred kindred with autosomal recessive spondylocostal dysostosis.

Seven members of a large inbred kindred with autosomal recessive spondylocostal dysostosis were examined clinically, radiographically, and sonographically. The subjects were three adults, one adolescent, and three children under 3 years of age. One child was the offspring of a first cousin marriage which showed quasi-dominant inheritance. Six subjects had short stature owing to widespread vertebral dyssegmentation with variable reduction in rib number and rib fusion. One subject was of normal stature, had limited vertebral dyssegmentation, an extra rib, and no rib fusion. Five subjects showed the plagiocephaly-torticollis sequence. Four of the five male subjects had inguinal herniation on one or both sides. All subjects had normal renal ultrasonography. The youngest subject died of cardiopulmonary complications and is thought to represent one extreme in the expressivity of the gene in this kindred.

Economic impact of Alzheimer's disease in the United Kingdom. Cost of care and disease severity for non-institutionalised patients with Alzheimer's disease.

BACKGROUND: While the costs associated with Alzheimer's disease have been shown to be significant, there are few data relating cost of care to severity of the disease. AIMS: We aimed to compare the costs associated with different severities of Alzheimer's disease with those incurred by control subjects over a three-month period. METHOD: In this cross-sectional, multicentre, naturalistic analysis, non-institutionalised patients with Alzheimer's disease (128), their care-givers (128), and 56 matched controls were interviewed once to establish resource use over the previous three months. Patients were stratified into three severity groups according to their Mini Mental State Examination score. Costs were calculated from the perspective of society as a whole. RESULTS: Over the three-month period, total mean cost per control subject (387 Pounds) was minor compared with mean cost incurred by patients with mild (6616 Pounds), moderate (10,250 Pounds) and severe (13,593 Pounds) Alzheimer's disease. Indirect cost, mainly time spent by care-givers, was the main cost component in all groups (68.6%), followed by direct medical costs (24.7%). CONCLUSIONS: The cost of care for an Alzheimer's disease patient is directly related to the severity of the patients illness.