Key factors in the decision-making process for mastectomy alone or breast reconstruction: A qualitative analysis.

Breast cancer is the most common cancer to affect New Zealand women. Women diagnosed face several decisions regarding surgical treatment, including whether to undergo lumpectomy, mastectomy, or breast reconstruction. Reconstructive surgery adds an additional layer of complexity, with several reconstructive options, each associated with differing surgical and recovery times. Furthermore, surgical decisions are often made under time-pressure and significant diagnostic distress, therefore provision of good information to support decision-making is crucial to adequately inform women of their options. We interviewed 24 women who had undergone breast surgery within the preceding 12 months to assess the key factors leading to their decision to opt for their chosen surgical procedure. Interviews revealed that decision-making was complex and involved multiple factors. Women were ultimately confronted with assessing feminine identity versus survival. Whether opting for breast reconstruction or not, women were fearful of what surgery would involve and how their reconstructed breast or mastectomy scar might look following surgery. Shared decision-making between patient and clinician can mitigate this fear and provide women with a sense of autonomy over their health decisions. Provision of visual depictions of surgical outcomes was not routinely provided to those interviewed but was expressed as important to help women manage surgical expectations. Therefore our findings support the multi-modal presentation of diagnostic and treatment information to support decision-making. Likewise, women reported feeling unsupported in their decision not to undergo breast reconstruction, suggesting a need to develop resources to provide women with positive discussions about 'going flat'.

Highly effective prophylaxis with ertapenem for transrectal ultrasound-guided prostate biopsy: effects on overall antibiotic use and inpatient hospital exposure.

BACKGROUND: Ertapenem prophylaxis for transrectal ultrasound-guided prostate biopsy (TRUS-PB) has proven highly effective at our institution. A subsequent study showed no selection for carbapenem resistance, but antimicrobial stewardship concerns remained. AIM: To assess the effects of this prophylaxis on overall antibiotic consumption and exposure to the hospital environment. METHODS: All men undergoing TRUS-PB from November 2006 to July 2019 were included. Hospital records of men presenting within 30 days of biopsy were searched to determine whether post-biopsy infection (PBI) occurred, antibiotic usage, and duration of hospitalization. Prophylaxis during the pre-ertapenem period (period 1: 2006 to 2012) was oral ciprofloxacin for three days, with oral amoxicillin-clavulanate added in 2009. During the subsequent period (period 2: 2012 to 2019) a single intramuscular dose of ertapenem was used. FINDINGS: From periods 1 and 2, 1663 and 2357 men, respectively, were included. Median age was 65 years for both groups. Between periods 1 and 2, PBI incidence decreased from 2.65% to 0.34% (risk ratio: 0.13; 95% confidence interval (CI): 0.06, 0.27), and PBI-related bacteraemia from 1.14% to 0.04% (0.04; 0.01, 0.22), with a single bacteraemia during period 2. PBI treatment antibiotic consumption decreased from 57.6 to 4.3 defined daily doses (DDDs) per 100 biopsies (mean difference: -53.3; 95% CI: -73.1, -33.5) and overall consumption (treatment plus prophylaxis) decreased from 580.8 to 104.3 DDDs per 100 biopsies (mean difference: -476.5). PBI-related hospitalized bed-days per 100 biopsies decreased from 9.44 to 0.89 (mean difference: -8.55; 95% CI: -12.31, -4.79). CONCLUSION: Ertapenem prophylaxis was highly effective and resulted in marked reductions in overall antibiotic consumption and inpatient bed-days. Effective prophylaxis has advantages from an antimicrobial stewardship perspective.

Factors affecting knee abduction during weight-bearing activities in individuals with anterior cruciate ligament reconstruction.

OBJECTIVE: To investigate if muscle strength and muscle activation patterns are associated with increased knee abduction during two functional tasks, commonly used in rehabilitation for individuals with anterior cruciate ligament reconstruction (ACLR). DESIGN: Cross-sectional study. SETTING: Laboratory. PARTICIPANTS: 24 women and 29 men approximately 7 months after ACLR. MAIN OUTCOME MEASURES: Isometric peak torque of the trunk and lower extremity muscles were determined during maximal voluntary contractions. Trunk and lower extremity average muscle activation amplitude and peak knee abduction were evaluated during the single-leg squat (SLS) and the single-leg hop for distance (SLHD) for the injured side. Separate backward regressions were performed for men and women. RESULTS: In women, lower knee flexion and extension strength were associated with greater peak knee abduction during the SLS (B = 4.63-18.26, p ≤ 0.036); lower knee flexion strength and iliocostalis activation on the non-injured side were associated with greater peak knee abduction during the SLHD (B = 0.60-20.48, p ≤ 0.043). No associations between muscle function and peak knee abduction were found in men. CONCLUSIONS: Muscle function may contribute differently to knee abduction in men and women after ACLR. This should be considered when designing rehabilitation programs to reduce knee abduction in these patients.

Integrating a newly developed BAC-based physical mapping resource for Lolium perenne with a genome-wide association study across a L. perenne European ecotype collection identifies genomic contexts associated with agriculturally important traits.

BACKGROUND AND AIMS: Lolium perenne (perennial ryegrass) is the most widely cultivated forage and amenity grass species in temperate areas worldwide and there is a need to understand the genetic architectures of key agricultural traits and crop characteristics that deliver wider environmental services. Our aim was to identify genomic regions associated with agriculturally important traits by integrating a bacterial artificial chromosome (BAC)-based physical map with a genome-wide association study (GWAS). METHODS: BAC-based physical maps for L. perenne were constructed from ~212 000 high-information-content fingerprints using Fingerprint Contig and Linear Topology Contig software. BAC clones were associated with both BAC-end sequences and a partial minimum tiling path sequence. A panel of 716 L. perenne diploid genotypes from 90 European accessions was assessed in the field over 2 years, and genotyped using a Lolium Infinium SNP array. The GWAS was carried out using a linear mixed model implemented in TASSEL, and extended genomic regions associated with significant markers were identified through integration with the physical map. KEY RESULTS: Between ~3600 and 7500 physical map contigs were derived, depending on the software and probability thresholds used, and integrated with ~35 k sequenced BAC clones to develop a resource predicted to span the majority of the L. perenne genome. From the GWAS, eight different loci were significantly associated with heading date, plant width, plant biomass and water-soluble carbohydrate accumulation, seven of which could be associated with physical map contigs. This allowed the identification of a number of candidate genes. CONCLUSIONS: Combining the physical mapping resource with the GWAS has allowed us to extend the search for candidate genes across larger regions of the L. perenne genome and identified a number of interesting gene model annotations. These physical maps will aid in validating future sequence-based assemblies of the L. perenne genome.

Randomised controlled trial to evaluate the effect of foot trimming before and after first calving on subsequent lameness episodes and productivity in dairy heifers.

The objective of this study was to assess both independent and combined effects of routine foot trimming of heifers at 3 weeks pre-calving and 100 days post calving on the first lactation lameness and lactation productivity. A total of 419 pre-calving dairy heifers were recruited from one heifer rearing operation over a 10-month period. Heifers were randomly allocated into one of four foot trimming regimens; pre-calving foot trim and post-calving lameness score (Group TL), pre-calving lameness score and post-calving foot trim (Group LT), pre-calving foot trim and post-calving foot trim (Group TT), and pre-calving lameness score and post-calving lameness score (Group LL, control group). All heifers were scored for lameness at 24 biweekly time points for 1 year following calving, and first lactation milk production data were collected. Following calving, 172/419 (41.1%) of heifers became lame during the study (period prevalence), with lameness prevalence at each time-point following calving ranging from 48/392 (12.2%) at 29-42 days post-calving to 4/379 (1.1%) between 295 and 383 days after calving. The effects of the four treatment groups were not significantly different from each other for overall lameness period prevalence, biweekly lameness point prevalence, time to first lameness event, type of foot lesion identified at dry off claw trimming, or the 4% fat corrected 305-day milk yield. However, increased odds lameness was significantly associated with a pre-calving trim alone (P = 0.044) compared to the reference group LL. The odds of heifer lameness were highest between 0 and 6 weeks post-partum, and heifer farm destination was significantly associated with lameness (OR 2.24), suggesting that even at high standard facilities, environment and management systems have more effect on heifer foot health than trimming.

Selective attention in dairy cattle.

In a replication of Reynolds (1961), two cows learned to discriminate between compound stimuli in a forced choice procedure where pushing through a one-way gate marked with a red cross (S+) gave access to food. Pushing through a one-way gate marked with a yellow triangle (S-) gave no access to food. To investigate whether shape or colour was controlling behaviour, probe tests varied either the shape or the colour of the stimuli (e.g., a red vs. a yellow cross, and a red cross vs. a red triangle). Results suggested control by colour rather than shape, as the gate marked with the red stimulus was chosen more than the gate marked with the yellow stimulus regardless of stimulus shape, and when two shapes of the same colour (either red or yellow) were presented, cows chose both equally. Further probe tests with painted red, white, and yellow stimuli showed that the cows had learned to avoid yellow rather than to approach red, suggesting discriminative behaviour was controlled by the colour of the negative stimulus and not by either aspect of the positive stimulus. It is not clear why the negative stimulus was more salient, but it may reflect a tendency for cows to learn to avoid farm handling practices which involve mainly negative stimuli.

Australasian Society of Infectious Diseases updated guidelines for the management of Clostridium difficile infection in adults and children in Australia and New Zealand.

The incidence of Clostridium difficile infection (CDI) continues to rise, whilst treatment remains problematic due to recurrent, refractory and potentially severe nature of disease. The treatment of C. difficile is a challenge for community and hospital-based clinicians. With the advent of an expanding therapeutic arsenal against C. difficile since the last published Australasian guidelines, an update on CDI treatment recommendations for Australasian clinicians was required. On behalf of the Australasian Society of Infectious Diseases, we present the updated guidelines for the management of CDI in adults and children.

Germplasm dynamics: the role of ecotypic diversity in shaping the patterns of genetic variation in Lolium perenne.

Perennial ryegrass (Lolium perenne) is the most widely grown temperate grass species globally. Intensive plant breeding in ryegrass compared to many other crops species is a relatively recent exercise (last 100 years) and provides an interesting experimental system to trace the extent, impact and trajectory of undomesticated ecotypic variation represented in modern ryegrass cultivars. To explore germplasm dynamics in Lolium perenne, 2199 SNPs were genotyped in 716 ecotypes sampled from 90 European locations together with 249 cultivars representing 33 forage/amenity accessions. In addition three pseudo-cross mapping populations (450 individual recombinants) were genotyped to create a consensus genetic linkage map. Multivariate analyses revealed strong differentiation between cultivars with a small proportion of the ecotypic variation captured in improved cultivars. Ryegrass cultivars generated as part of a recurrent selection programme (RSP) are strongly associated with a small number of geographically localised Italian ecotypes which were among the founders of the RSP. Changes in haplotype frequency revealed signatures of selection in genes putatively involved in water-soluble carbohydrate (WSC) accumulation (a trait selected in the RSP). Retrospective analysis of germplasm in breeding programmes (germplasm dynamics) provides an experimental framework for the identification of candidate genes for novel traits such as WSC accumulation in ryegrass.

Genetic-geographic correlation revealed across a broad European ecotypic sample of perennial ryegrass (Lolium perenne) using array-based SNP genotyping.

KEY MESSAGE: Publically available SNP array increases the marker density for genotyping of forage crop, Lolium perenne. Applied to 90 European ecotypes composed of 716 individuals identifies a significant genetic-geographic correlation. Grassland ecosystems are ubiquitous across temperate and tropical regions, totalling 37% of the terrestrial land cover of the planet, and thus represent a global resource for understanding local adaptations to environment. However, genomic resources for grass species (outside cereals) are relatively poor. The advent of next-generation DNA sequencing and high-density SNP genotyping platforms enables the development of dense marker assays for population genetics analyses and genome-wide association studies. A high-density SNP marker resource (Illumina Infinium assay) for perennial ryegrass (Lolium perenne) was created and validated in a broad ecotype collection of 716 individuals sampled from 90 sites across Europe. Genetic diversity within and between populations was assessed. A strong correlation of geographic origin to genetic structure was found using principal component analysis, with significant correlation to longitude and latitude (P < 0.001). The potential of this array as a resource for studies of germplasm diversity and identifying traits underpinning adaptive variation is highlighted.

Influence of turbulence on the wake of a marine current turbine simulator.

Marine current turbine commercial prototypes have now been deployed and arrays of multiple turbines under design. The tidal flows in which they operate are highly turbulent, but the characteristics of the inflow turbulence have not being considered in present design methods. This work considers the effects of inflow turbulence on the wake behind an actuator disc representation of a marine current turbine. Different turbulence intensities and integral length scales were generated in a large eddy simulation using a gridInlet, which produces turbulence from a grid pattern on the inlet boundary. The results highlight the significance of turbulence on the wake profile, with a different flow regime occurring for the zero turbulence case. Increasing the turbulence intensity reduced the velocity deficit and shifted the maximum deficit closer to the turbine. Increasing the integral length scale increased the velocity deficit close to the turbine due to an increased production of turbulent energy. However, the wake recovery was increased due to the higher rate of turbulent mixing causing the wake to expand. The implication of this work is that marine current turbine arrays could be further optimized, increasing the energy yield of the array when the site-specific turbulence characteristics are considered.

Effectiveness of the 2009 seasonal influenza vaccine against pandemic influenza A(H1N1)2009 in healthcare workers in New Zealand, June-August 2009.

There is uncertainty whether the 2009 seasonal influenza vaccination influences the risk of infection with the 2009 pandemic influenza A(H1N1) virus. This issue was investigated in 548 healthcare workers from Capital and Coast District Health Board, Wellington, New Zealand, presenting with influenza-like illness during the influenza pandemic between June and August 2009. All workers completed an assessment sheet and had a nasopharyngeal swab tested by real-time RT-PCR. The risk of pandemic influenza A(H1N1) infection associated with the 2009 seasonal inactivated trivalent influenza vaccine was determined by logistic regression, with adjustment for potential confounding variables. In 96 workers pandemic influenza A(H1N1) RNA was detected and 452 tested negative. The multivariate analysis did not show any effect of vaccination on PCR-confirmed influenza A(H1N1)2009 infection (odds ratio 1.2, 95% confidence interval 0.7­1.9, p=0.48). We conclude that 2009 seasonal influenza vaccination had no protective effect against influenza A(H1N1)2009 infection amongst healthcare workers. To protect against further waves of the current pandemic influenza or future pandemics in which the influenza virus is antigenically distinct from contemporary seasonal influenza viruses, it would be necessary to vaccinate with a specific pandemic influenza vaccine, or a seasonal influenza vaccine that includes the pandemic influenza serotype.

An investigation of colour discrimination with horses (Equus caballus).

The ability of four horses (Equus caballus) to discriminate coloured (three shades of blue, green, red, and yellow) from grey (neutral density) stimuli, produced by back projected lighting filters, was investigated in a two response forced-choice procedure. Pushes of the lever in front of a coloured screen were occasionally reinforced, pushes of the lever in front of a grey screen were never reinforced. Each colour shade was randomly paired with a grey that was brighter, one that was dimmer, and one that approximately matched the colour in terms of brightness. Each horse experienced the colours in a different order, a new colour was started after 85% correct responses over five consecutive sessions or if accuracy showed no trend over sessions. All horses reached the 85% correct with blue versus grey, three horses did so with both yellow and green versus grey. All were above chance with red versus grey but none reached criterion. Further analysis showed the wavelengths of the green stimuli used overlapped with the yellow. The results are consistent with histological and behavioural studies that suggest that horses are dichromatic. They differ from some earlier data in that they indicate horses can discriminate yellow and blue, but that they may have deficiencies in discriminating red and green.

Invasive pneumococcal disease in New Zealand 1998-2005: capsular serotypes and antimicrobial resistance.

Isolates from 3903 cases of invasive pneumococcal disease (IPD) were referred to the national reference laboratory over the 8 years, 1998-2005, as part of the laboratory-based surveillance of this disease in New Zealand. All isolates were serotyped and their antimicrobial susceptibility was tested. The incidence of IPD was highest in young children, with an average annual incidence of 100.8/100,000 in infants aged <2 years. There were changes in the prevalence of several of the serotypes during the 8-year period. Overall the seven serotypes included in the 7-valent pneumococcal conjugate vaccine, 4, 6B, 9V, 14, 18C, 19F and 23F, were the most common serotypes and accounted for 80.9% of the disease in infants aged <2 years. There was no overall change in penicillin resistance or non-susceptibility during the 8 years, and rates were 7.1% and 17.1%, respectively, in 2005. In contrast, cefotaxime and erythromycin resistance increased to reach 3.1% and 12.2%, respectively, by 2005.

Global transmission of prolyliminopeptidase-negative Neisseria gonorrhoeae strains: implications for changes in diagnostic strategies.

BACKGROUND: Species confirmation of Neisseria gonorrhoeae is commonly performed with biochemical kits, rely on the activity of the enzyme prolyliminopeptidase (PIP). This enzyme has previously been considered to be almost universally present in N gonorrhoeae. However, increasing numbers of N gonorrhoeae isolates lacking PIP activity have been identified. OBJECTIVES: To investigate the possibility of a widespread transmission of one or several N gonorrhoeae PIP-negative strains among several countries worldwide. METHODS: PIP-negative N gonorrhoeae isolates cultured from 2001 to 2004 in Australia, New Zealand and Scotland were comprehensively characterised and compared with previous data from England and Denmark. All isolates were characterised by antibiotic susceptibility testing, serovar determination, pulsed-field gel electrophoresis (PFGE), opa-typing, sequencing of the entire porB gene and N gonorrhoeae multiantigen sequence typing (NG-MAST). RESULTS: Most (83%) of the viable Australian isolates, and all the New Zealand and Scottish isolates were assigned serovar IB-4, with similar antibiograms, nearly identical porB1b gene sequences, identical (ST210) or highly related (ST292, ST1259) NG-MAST STs, and indistinguishable or related PFGE fingerprints as well as opa-types. The isolates showed characteristics indistinguishable or highly related to the previously described English and Danish outbreak strain. CONCLUSIONS: A comprehensive characterisation indicates a widespread dissemination, mainly among men who have sex with men (MSM), of indistinguishable and highly related genotypes that have evolved from a single N gonorrhoeae PIP-negative serovar IB-4 strain among several countries worldwide. An increased awareness of PIP-negative N gonorrhoeae strains is crucial and changes in the diagnostic strategies may need to be considered.

Bloodstream infections in a secondary and tertiary care hospital setting.

BACKGROUND: Bloodstream infections (BSI) occurring in community and health-care settings vary with the patient group and treatment of underlying medical conditions. We studied the clinical infectious syndromes occurring in patients with positive blood cultures routinely obtained at a regional secondary and tertiary care hospital. METHODS: BSI were categorized as either community-acquired (C-BSI), or health-care-associated (H-BSI) acquired either as a (i) non-inpatient (outpatient) or (ii) hospital inpatient. Clinical information was collected prospectively during the 1-year study. RESULTS: There were 193 C-BSI and 230 H-BSI. The large majority of C-BSI were caused by bacterial pathogens susceptible to narrow-spectrum antibiotics, particularly in children. Cefuroxime was active against 90% of C-BSI isolates and 46% of H-BSI isolates, excluding anaerobes. Of all H-BSI, the 35% occurring in outpatients had a similar source, microbiological cause and bacterial susceptibilities to the inpatients. H-BSI were infrequently due to enterococci (4%), Candida (3%) or methicillin-resistant Staphylococcus aureus (0.4%). No BSI were due to vancomycin-resistant enterococci or extended-spectrum beta-lactamase producing Enterobacteriaciae. I.v. catheters, predominantly central lines, were the source of 60% of all H-BSI, mostly in haematology-oncology or neonatal patients. Mortality at 1 month was 12% overall for both C-BSI and H-BSI, varying markedly by underlying disease and increasing age (for C-BSI). CONCLUSION: In this population, C-BSI have remained susceptible to narrow-spectrum antibiotics, whereas H-BSI due to multiresistant organisms were rare. Obtaining a history of recent medical procedures is important for community patients presenting with a BSI.

Characterization of prolyl iminopeptidase-deficient Neisseria gonorrhoeae.

Prolyl iminopeptidase (PIP) is an enzyme produced by Neisseria gonorrhoeae, the detection of which is incorporated into several commercial test panels. In this report we describe two distinct mutations in the pip gene which account for the loss of PIP activity.

Congenital malaria in a preterm infant.

A case of congenital malaria in a preterm newborn infant is presented. The case illustrates the difficulty of early diagnosis, and the atypical nature of presentation in a preterm infant.

Intracranial and spinal tuberculosis requiring neurosurgical intervention. The Wellington Hospital experience 1998-2001.

AIMS: To describe the Wellington Neurosurgical Unit's recent experience of managing tuberculosis between January 1998 and January 2001. METHODS: Patients with microbiologically confirmed tuberculosis of the central nervous system and whose management included surgery are described. Personal recall and review of the hospital records were used to extract relevant data. RESULTS: Five patients were identified. As well as involvement of the brain parenchyma, meninges, spinal cord or spinal column, all had evidence of tuberculosis elsewhere. All but one patient deteriorated neurologically after being started on antituberculous chemotherapy. CONCLUSIONS: The number of patients presenting with neurotuberculosis appears to have increased recently in the Wellington region. The high proportion of paradoxical progression in our series is unusual. Neurosurgical intervention may be required for diagnosis, to treat hydrocephalus, or to relieve mass effect. Management is prolonged and often complex, and close co-operation is required between the neurosurgical team and a physician experienced in the management of tuberculosis.