Online physiotherapy for people with axial spondyloarthritis: quantitative and qualitative data from a cohort study.

Life-long exercise is essential in axial spondyloarthritis (axSpA) management; however, long-term adherence is challenging. Online exercise programmes are an alternative to face-to-face physiotherapy. (1) To measure adherence to a 12-month, individualised, online physiotherapy programme for people with axSpA, and investigate the effects on disease activity, spinal mobility, work ability, quality of life and function. (2) To investigate associations between programme adherence and outcomes. (3) To explore participants' views of the programme and factors affecting adherence. Participants were 'non-exercisers' recruited from rheumatology outpatient services. Adherence was measured using online diary entries. Outcomes included the BATH indices, health status (EQ5D), Ankylosing Spondylitis Quality of Life (ASQOL), exercise capacity (6MWT), Work, Productivity and Activity Impairment in AS (WPAI), Exercise Attitude Questionnaire (EAQ) and Exercise Motivations Inventory-2 (EMI-2) at baseline, 6 and 12 months. Interviews determined views on the intervention and factors affecting adherence. Fifty participants were recruited. Over the 52-week intervention, adherence (five times/week) ranged from 19% (± 30%) to 44% (± 35%). Significant improvements were found in disease activity (BASDAI), spinal mobility (BASMI), 6MWT, AsQoL and EQ5D-VAS at 6 and 12 months. There were no associations between adherence and baseline variables or demographics. Interviews suggested support from others, routine, and feeling the benefit positively affected adherence. Conversely, lack of motivation, life events and symptoms negatively affected adherence. A 12-month online physiotherapy programme significantly improved symptoms in people with axSpA who were not regular exercisers. Adherence reduced over the intervention period. Online exercise programmes may benefit people with axSpA; however, strategies to improve adherence are required.

Level of adherence to prescribed exercise in spondyloarthritis and factors affecting this adherence: a systematic review.

Adherence is a primary determinant of the effectiveness of any intervention. Exercise is considered essential in the management of spondyloarthritis (SpA); however, the overall adherence to exercise programmes and factors affecting adherence are unknown. The aim of this systematic review was to examine measures of, and factors influencing adherence to, prescribed exercise programmes in people with SpA. A search was performed in August 2018 using five data bases; the Cochrane library, CINAHL, EMBASE, MEDLINE, and Web of Science Collections. Inclusion criteria were: studies with adults (> 18 years) with SpA, with a prescribed exercise intervention or educational programme with the aim of increasing exercise participation. Article quality was independently assessed by two assessors. Extracted descriptive data included: populations, interventions, measures of adherence and factors affecting adherence. Percentage adherence rates to prescribed exercises were calculated if not reported. Nine studies were included with a total of 658 participants, 95% of participants had a diagnosis of ankylosing spondylitis. Interventions and measurement of adherence varied, making comparisons difficult. Rates of adherence ranged from 51.4 to 95%. Single studies identified; adherence improved following educational programmes, and higher disease severity and longer diagnostic delays were associated with higher adherence. Conflicting evidence was found as to whether supervision of exercise improved adherence. Three consecutive studies demonstrated adherence reduced over time. Adherence to prescribed exercise in SpA was poorly reported and predominately for people with AS. The levels of adherence and factors affecting prescribed exercise in SpA remain unclear. Future research should measure adherence across a longer time period and investigate possible factors which may influence adherence.

Characteristics of a protocol to collect objective physical activity/sedentary behaviour data in a large study: Seniors USP (understanding sedentary patterns).

The Seniors USP study measured sedentary behaviour (activPAL3, 9 day wear) in older adults. The measurement protocol had three key characteristics: enabling 24-hour wear (monitor location, waterproofing); minimising data loss (reducing monitor failure, staff training, communication); and quality assurance (removal by researcher, confidence about wear). Two monitors were not returned; 91% (n=700) of returned monitors had 7 valid days of data. Sources of data loss included monitor failure (n=11), exclusion after quality assurance (n=5), early removal for skin irritation (n=8) or procedural errors (n=10). Objective measurement of physical activity and sedentary behaviour in large studies requires decisional trade-offs between data quantity (collecting representative data) and utility (derived outcomes that reflect actual behaviour).

TAxonomy of Self-reported Sedentary behaviour Tools (TASST) framework for development, comparison and evaluation of self-report tools: content analysis and systematic review.

OBJECTIVE: Sedentary behaviour (SB) has distinct deleterious health outcomes, yet there is no consensus on best practice for measurement. This study aimed to identify the optimal self-report tool for population surveillance of SB, using a systematic framework. DESIGN: A framework, TAxonomy of Self-reported Sedentary behaviour Tools (TASST), consisting of four domains (type of assessment, recall period, temporal unit and assessment period), was developed based on a systematic inventory of existing tools. The inventory was achieved through a systematic review of studies reporting SB and tracing back to the original description. A systematic review of the accuracy and sensitivity to change of these tools was then mapped against TASST domains. DATA SOURCES: Systematic searches were conducted via EBSCO, reference lists and expert opinion. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: The inventory included tools measuring SB in adults that could be self-completed at one sitting, and excluded tools measuring SB in specific populations or contexts. The systematic review included studies reporting on the accuracy against an objective measure of SB and/or sensitivity to change of a tool in the inventory. RESULTS: The systematic review initially identified 32 distinct tools (141 questions), which were used to develop the TASST framework. Twenty-two studies evaluated accuracy and/or sensitivity to change representing only eight taxa. Assessing SB as a sum of behaviours and using a previous day recall were the most promising features of existing tools. Accuracy was poor for all existing tools, with underestimation and overestimation of SB. There was a lack of evidence about sensitivity to change. CONCLUSIONS: Despite the limited evidence, mapping existing SB tools onto the TASST framework has enabled informed recommendations to be made about the most promising features for a surveillance tool, identified aspects on which future research and development of SB surveillance tools should focus. TRIAL REGISTRATION NUMBER: International prospective register of systematic reviews (PROPSPERO)/CRD42014009851.

Validity of the activPAL3 activity monitor in people moderately affected by Multiple Sclerosis.

Walking is the primary form of physical activity performed by people with Multiple Sclerosis (MS), therefore it is important to ensure the validity of tools employed to measure walking activity. The aim of this study was to assess the criterion validity of the activPAL3 activity monitor during overground walking in people with MS. Validity of the activPAL3 accelerometer was compared to video observation in 20 people moderately affected by MS. Participants walked 20-30m twice along a straight quiet corridor at a comfortable speed. Inter-rater reliability of video observations was excellent (all intraclass correlations >0.99). The mean difference (activPAL3- mean of raters) was -4.70±9.09, -4.55s±10.76 and 1.11s±1.11 for steps taken, walking duration and upright duration respectively. These differences represented 8.7%, 10.0% and 1.8% of the mean for each measure respectively. The activPAL3 tended to underestimate steps taken and walking duration in those who walked at cadences of ≤38 steps/min by 60% and 47%, respectively. The activPAL3 is valid for measuring walking activity in people moderately affected by MS. It is accurate for upright duration regardless of cadence. In participants with slow walking cadences, outcomes of steps taken and walking duration should be interpreted with caution.

The effectiveness and satisfaction of web-based physiotherapy in people with spinal cord injury: a pilot randomised controlled trial.

STUDY DESIGN: A pilot randomised controlled trial. OBJECTIVES: The aims of this study were to evaluate the effectiveness and participant satisfaction of web-based physiotherapy in people with spinal cord injury (SCI). SETTING: Community patients of a national spinal injury unit in a university teaching hospital, Scotland, UK. METHODS: Twenty-four participants were recruited and randomised to receive 8 weeks of web-based physiotherapy (intervention), twice per week, or usual care (control). Individual exercise programmes were prescribed based on participants' abilities. The intervention was delivered via a website (www.webbasedphysio.com) and monitored and progressed remotely by the physiotherapist. RESULTS: Participants logged on to the website an average of 1.4±0.8 times per week. Between-group differences, although not significant, were more pronounced for the 6-min walk test. Participants were positive about using web-based physiotherapy and stated that they would be happy to use it again and would recommend it to others. Overall, it was rated as either good or excellent. CONCLUSIONS: Web-based physiotherapy was feasible and acceptable for people with SCI. Participants achieved good compliance with the intervention and rated the programme highly and beneficial for health and well-being at various states after injury. The results of this study warrant further work with a more homogeneous sample. SPONSORSHIP: This study was funded by the Queen Elizabeth National Spinal Injuries Unit, Glasgow, UK.

Web-based physiotherapy for people with axial spondyloarthritis (WEBPASS) - a study protocol.

BACKGROUND: Evidence suggests people with axial spondyloarthritis (axial SpA) should exercise up to five times per week but lack of time, symptoms, cost and distance are barriers to regular exercise in axial SpA. Personalised exercise programmes delivered via the internet might support people with axial SpA to reach these exercise targets. The aim of this study is to investigate the effect of, and adherence to, a 12 month personalised web-based physiotherapy programme for people with axial SpA. METHODS: Fifty people with axial SpA will be recruited to this prospective, interventional cohort study. Each participant will be assessed by a physiotherapist and an individualised exercise programme set up on www.webbasedphysio.com . Participants will be asked to complete their programme five times per week for 12 months. With the exception of adherence, data will be collected at baseline, 6 and 12 months. DISCUSSION: The primary outcome measure is adherence to the exercise programme over each four week cycle (20 sessions maximum per cycle) and over the 12 months. Secondary measures include function (BASFI), disease activity (BASDAI), work impairment (WPAI:SpA), quality of life (ASQoL, EQ5D), attitude to exercise (EMI-2, EAQ), spinal mobility (BASMI), physical activity and the six minute walk test. Participants will also be interviewed to explore their adherence, or otherwise, to the intervention. This study will determine the adherence and key clinical outcomes of a targeted web-based physiotherapy programme for axial SpA. This data will inform clinical practice and the development and implementation of similar programmes. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02666313 , 20th January 2016.

Estimating reassortment rates in co-circulating Eurasian swine influenza viruses.

Swine have often been considered as a mixing vessel for different influenza strains. In order to assess their role in more detail, we undertook a retrospective sequencing study to detect and characterize the reassortants present in European swine and to estimate the rate of reassortment between H1N1, H1N2 and H3N2 subtypes with Eurasian (avian-like) internal protein-coding segments. We analysed 69 newly obtained whole genome sequences of subtypes H1N1-H3N2 from swine influenza viruses sampled between 1982 and 2008, using Illumina and 454 platforms. Analyses of these genomes, together with previously published genomes, revealed a large monophyletic clade of Eurasian swine-lineage polymerase segments containing H1N1, H1N2 and H3N2 subtypes. We subsequently examined reassortments between the haemagglutinin and neuraminidase segments and estimated the reassortment rates between lineages using a recently developed evolutionary analysis method. High rates of reassortment between H1N2 and H1N1 Eurasian swine lineages were detected in European strains, with an average of one reassortment every 2-3 years. This rapid reassortment results from co-circulating lineages in swine, and in consequence we should expect further reassortments between currently circulating swine strains and the recent swine-origin H1N1v pandemic strain.

Development and validation of a physical activity monitor for use on a wheelchair.

STUDY DESIGN: Keeping physically active is important for people who mobilize using a wheelchair. However, current tools to measure physical activity in the wheelchair are either not validated or limited in their application. The purpose of this study was to develop and validate a monitoring system to measure wheelchair movement. METHODS: The system developed consisted of a tri-axial accelerometer placed on the wheel of a wheelchair and an analysis algorithm to interpret the acceleration signals. The two accelerometer outputs in the plane of the wheel were used to calculate the angle of the wheel. From this, outcome measures of wheel revolutions, absolute angle and duration of movement were derived and the direction of movement (forwards or backwards) could be distinguished. Concurrent validity was assessed in comparison with video analysis in 14 people with spinal cord injury using their wheelchair on an indoor track and outdoor wheelchair skills course. Validity was assessed using intraclass correlation coefficients (ICC(2,1)) and Bland-Altman plots. RESULTS: The monitoring system demonstrated excellent validity for wheel revolutions, absolute angle and duration of movement (ICC(2,1)>0.999, 0.999, 0.981, respectively) in both manual and powered wheelchairs, when the wheelchair was propelled forwards and backwards, and for movements of various durations. CONCLUSION: This study has found this monitoring system to be an accurate and objective tool for measuring detailed information on wheelchair movement and maneuvering regardless of the propulsion technique, direction and speed.

A role for rubredoxin in oxidative stress protection in Desulfovibrio vulgaris: catalytic electron transfer to rubrerythrin and two-iron superoxide reductase.

Desulfovibrio vulgaris rubredoxin, which contains a single [Fe(SCys)4] site, is shown to be a catalytically competent electron donor to two enzymes from the same organism, namely, rubrerythrin and two-iron superoxide reductase (a.k.a. rubredoxin oxidoreductase or desulfoferrodoxin). These two enzymes have been implicated in catalytic reduction of hydrogen peroxide and superoxide, respectively, during periods of oxidative stress in D. vulgaris, but their proximal electron donors had not been characterized. We further demonstrate the incorrectness of a previous report that rubredoxin is not an electron donor to the superoxide reductase and describe convenient assays for demonstrating the catalytic competence of all three proteins in their respective functions. Rubrerythrin is shown to be an efficient rubredoxin peroxidase in which the rubedoxin:hydrogen peroxide redox stoichiometry is 2:1 mol:mol. Using spinach ferredoxin-NADP+ oxidoreductase (FNR) as an artificial, but proficient, NADPH:rubredoxin reductase, rubredoxin was further found to catalyze rapid and complete reduction of all Fe3+ to Fe2+ in rubrerythrin by NADPH under anaerobic conditions. The combined system, FNR/rubredoxin/rubrerythrin, was shown to function as a catalytically competent NADPH peroxidase. Another small rubredoxin-like D. vulgaris protein, Rdl, could not substitute for rubredoxin as a peroxidase substrate of rubrerythrin. Similarly, D. vulgaris rubredoxin was demonstrated to efficiently catalyze reduction of D. vulgaris two-iron superoxide reductase and, when combined with FNR, to function as an NADPH:superoxide oxidoreductase. We suggest that, during periods of oxidative stress, rubredoxin could divert electron flow from the electron transport chain of D. vulgaris to rubrerythrin and superoxide reductase, thereby simultaneously protecting autoxidizable redox enzymes and lowering intracellular hydrogen peroxide and superoxide levels.

Five-gene cluster in Clostridium thermoaceticum consisting of two divergent operons encoding rubredoxin oxidoreductase- rubredoxin and rubrerythrin-type A flavoprotein- high-molecular-weight rubredoxin.

A five-gene cluster encoding four nonheme iron proteins and a flavoprotein from the thermophilic anaerobic bacterium Clostridium thermoaceticum (Moorella thermoacetica) was cloned and sequenced. Based on analysis of deduced amino acid sequences, the genes were identified as rub (rubredoxin), rbo (rubredoxin oxidoreductase), rbr (rubrerythrin), fprA (type A flavoprotein), and a gene referred to as hrb (high-molecular-weight rubredoxin). Northern blot analysis demonstrated that the five-gene cluster is organized as two subclusters, consisting of two divergently transcribed operons, rbr-fprA-hrb and rbo-rub. The rbr, fprA, and rub genes were expressed in Escherichia coli, and their encoded recombinant proteins were purified. The molecular masses, UV-visible absorption spectra, and cofactor contents of the recombinant rubrerythrin, rubredoxin, and type A flavoprotein were similar to those of respective homologs from other microorganisms. Antibodies raised against Desulfovibrio vulgaris Rbr reacted with both native and recombinant Rbr from C. thermoaceticum, indicating that this protein was expressed in the native organism. Since Rbr and Rbo have been recently implicated in oxidative stress protection in several anaerobic bacteria and archaea, we suggest a similar function of these proteins in oxygen tolerance of C. thermoaceticum.

Characterization and evolution of anthranilate 1,2-dioxygenase from Acinetobacter sp. strain ADP1.

The two-component anthranilate 1,2-dioxygenase of the bacterium Acinetobacter sp. strain ADP1 was expressed in Escherichia coli and purified to homogeneity. This enzyme converts anthranilate (2-aminobenzoate) to catechol with insertion of both atoms of O(2) and consumption of one NADH. The terminal oxygenase component formed an alpha(3)beta(3) hexamer of 54- and 19-kDa subunits. Biochemical analyses demonstrated one Rieske-type [2Fe-2S] center and one mononuclear nonheme iron center in each large oxygenase subunit. The reductase component, which transfers electrons from NADH to the oxygenase component, was found to contain approximately one flavin adenine dinucleotide and one ferredoxin-type [2Fe-2S] center per 39-kDa monomer. Activities of the combined components were measured as rates and quantities of NADH oxidation, substrate disappearance, product appearance, and O(2) consumption. Anthranilate conversion to catechol was stoichiometrically coupled to NADH oxidation and O(2) consumption. The substrate analog benzoate was converted to a nonaromatic benzoate 1,2-diol with similarly tight coupling. This latter activity is identical to that of the related benzoate 1, 2-dioxygenase. A variant anthranilate 1,2-dioxygenase, previously found to convey temperature sensitivity in vivo because of a methionine-to-lysine change in the large oxygenase subunit, was purified and characterized. The purified M43K variant, however, did not hydroxylate anthranilate or benzoate at either the permissive (23 degrees C) or nonpermissive (39 degrees C) growth temperatures. The wild-type anthranilate 1,2-dioxygenase did not efficiently hydroxylate methylated or halogenated benzoates, despite its sequence similarity to broad-substrate specific dioxygenases that do. Phylogenetic trees of the alpha and beta subunits of these terminal dioxygenases that act on natural and xenobiotic substrates indicated that the subunits of each terminal oxygenase evolved from a common ancestral two-subunit component.

Preparation and initial characterization of the compound I, II, and III states of iron methylchlorin-reconstituted horseradish peroxidase and myoglobin: models for key intermediates in iron chlorin enzymes.

To better understand the spectral properties of high valent and oxyferrous states in naturally occurring iron chlorin-containing proteins, we have prepared the oxoferryl compound I derivative of iron methylchlorin-reconstituted horseradish peroxidase (MeChl-HRP) and the compound II and oxyferrous compound III states of iron MeChl-reconstituted myoglobin. Initial spectral characterization has been carried out with UV-visible absorption and magnetic circular dichroism. In addition, the peroxidase activity of iron MeChl-HRP in pyrogallol oxidation has been found to be 40% of the rate for native HRP. Previous studies of oxoferryl chlorins have employed tetraphenylchlorins in organic solvents at low temperatures; stable oxyferrous chlorins have not been previously examined. The present study describes the compound I, II, and III states of histidine-ligated iron chlorins in a protein environment for the first time.

Electron paramagnetic resonance measurements of the ferrous mononuclear site of phthalate dioxygenase substituted with alternate divalent metal ions: direct evidence for ligation of two histidines in the copper(II)-reconstituted protein.

The metalloenzyme phthalate dioxygenase (PDO) contains two iron-based sites. A Rieske-type [2Fe-2S] cluster serves as an electron-transferring cofactor, and a mononuclear iron site is the putative site of substrate oxygenation. A reductase, which contains FMN and a plant-type [2Fe-2S] ferredoxin domain, transfers electrons from NADH to the Rieske center. Any of the metal ions, Fe(II), Cu(II), Co(II), Mn(II), and Zn(II), can be used to populate the mononuclear site, but only Fe(II) is competent for effecting hydroxylation. Nevertheless, studies of how these metal ions affect both the EPR spectra of the reduced Rieske site and the kinetics of electron transfer in the PDO system indicated that each of these metal ions binds tightly and affects the protein similarly. In this study, EPR spectra were obtained from samples in which iron of the mononuclear site was replaced with Cu(II). The use of (63)Cu(II), in combination with PDO obtained from cultures grown on media enriched in (15)N [using ((15)NH(4))(2)SO(4) as a sole nitrogen source], [delta,epsilon-(15)N]histidine, as well as natural abundance sources of nitrogen, enabled detailed spectral analysis of the superhyperfine structure of the Cu(II) EPR lines. These studies clearly show that two histidines are coordinated to the mononuclear site. Coupled with previous studies [Bertini, I., Luchinat, C., Mincione, G., Parigi, G., Gassner G. T., and Ballou, D. P. (1996) J. Bioinorg. Chem. 1, 468-475] that show the presence of one or two water molecules coordinated to the iron, it is suggested that the mononuclear site is similar to several other mononuclear nonheme iron proteins, including naphthalene dioxygenase, for which crystal structures are available. The lack of observable EPR interaction signals between Cu(II) in the mononuclear site and the reduced Rieske center of PDO suggest that the two sites are at least 12 A apart, which is similar to that found in the naphthalene dioxygenase crystal structure.

NADH peroxidase activity of rubrerythrin.

P. S. Alban et al. (J. Appl. Microbiol. (1998) 85, 875-882) reported that a mutant H2O2-resistant strain of Spirullum (S.) volutans showed constitutive overexpression of a protein whose amino acid sequence and molecular weight closely resembled that of a subunit of rubrerythrin, a non-heme iron protein with no known function. They also reported that the mutant strain, but not the wild-type, showed NADH peroxidase activity. Here we demonstrate that rubrerythrin and nigerythrin from Desulfovibrio vulgaris and rubrerythrin from Clostridium perfringens show NADH peroxidase activities in an in vitro system containing NADH, hydrogen peroxide, and a bacterial NADH oxidoreductase. The peroxidase specific activities of the rubrerythrins with the "classical" heme peroxidase substrate, o-dianisidine, are many orders of magnitude lower than that of horseradish peroxidase. These results are consistent with the phenotype of the H2O2-resistant strain of S. volutans. The reaction of reduced (i.e., all-ferrous) rubrerythrin with excess O2 takes several minutes, whereas the anaerobic reaction of reduced rubrerythrin with hydrogen peroxide is on the millisecond time scale and results in full oxidation of all iron centers to their ferric states. Rubrerythrins could, thus, function as the terminal components of NADH peroxidases in air-sensitive bacteria and archaea.

Non-haem iron-containing oxygenases involved in the microbial biodegradation of aromatic hydrocarbons.

A wide variety of aromatic hydrocarbons can be degraded aerobically by micro-organisms. A large fraction of the metabolic pathways are initiated by oxygenases containing Fe(II) at the active sites, which participates in the oxygenation and activation of the hydrocarbons. Mono-oxygenations and dioxygenations are found in these pathways. Some of these enzymes can catalyse either or both reactions, depending on the nature of the substrate. Two general themes are found: mononuclear Fe(II) centres that must be reduced by one electron at a time, or di-iron centres that can be reduced by two electrons. The electrons from NAD(P)H can be delivered by either an electron-transfer chain consisting of a flavin and one or more [2Fe-2S] centres, or a pterin. Proposed mechanisms generally involve higher oxidation states of the iron (Fe = O), analogous to those for P450, and peroxidase systems. These strong oxidants are necessary to oxidize aromatic and aliphatic compounds. Mechanisms currently considered viable for these reactions require significant changes in ligation during catalysis. The structures of the non-haem iron centres may be particularly well-suited for such transformations.

Uncoupling oxygen transfer and electron transfer in the oxygenation of camphor analogues by cytochrome P450-CAM. Direct observation of an intermolecular isotope effect for substrate C-H activation.

The hydroxylation of (1R)-camphor by cytochrome P450-CAM involves almost complete coupling of electron to oxygen transfer. Modifications at C-5 of camphor, the normal site of hydroxylation by P450-CAM, lead to as much as 98% uncoupling of electron and oxygen transfer as well as to decreases in the rate of electron uptake (up to 10-fold) and the rate of oxygenated product formation (up to 210-fold). Two modes of uncoupling are seen: (a) two-electron uncoupling in which the decrease in oxygenated product formation is balanced by increases in H2O2 formation and (b) four-electron "oxidase" uncoupling where the NADH/O2 ratio has changed from one to nearly two and relatively little H2O2 is formed. Both enantiomers of 5-methylenylcamphor are two-electron uncouplers, while (1R)- and (1S)-5,5-difluorocamphor and (1R)-9,9,9-d3-5,5-difluorocamphor are four-electron uncouplers. An intermolecular isotope effect of 11.7 is observed for oxygenation of C-9 in (1R)-5,5-difluorocamphor. With this substrate, the significant decrease in the rate of oxygenated product formation combined with the large isotope effect suggest that the rate-limiting step has switched from electron to oxygen transfer.

Coccidian/cyanobacterium-like body associated diarrhea in an Australian traveller returning from overseas.

Coccidian/cyanobacterium-like body (CLB) associated diarrhea occurred in a 42 yr old Australian woman returning from Bali, Indonesia. The patient had a diarrheal illness of 10 days duration with symptoms of explosive diarrhea, nausea, anorexia and fever. Fecal examination revealed CLBs which were detected in modified Ziehl-Neelsen stained fecal smears. No other bacterial or parasite pathogens were found. CLBs were variably acid fast, showed an intense blue auto-fluorescence under UV microscopy and appeared as non-refractile hyaline spheres in direct wet mounts, being 8-9 microns in diameter. The taxonomic status of CLBs has been unclear but recent evidence supports that they are a coccidian parasite of the genus Cyclospora, rather than cyanobacterium. There is no specific therapy for CLB enteritis and spontaneous recovery occurs after what may be a prolonged diarrheal illness. CLBs may be a previously unrecognized enteric pathogen although their role in the pathology of diarrheal illness is still undetermined. There is consistency in the clinical and laboratory findings amongst the reported cases and CLBs should be considered in persons with unexplained gastroenteritis, especially travellers returning from tropical regions.

The world economic crisis and the children: United States case study.

This is a review of the United States experience with issues of child health and services as they relate to changes in economic trends. No existing data systems are entirely adequate for reporting on the current health status of children. An important consideration for the monitoring of children's health in the United States is the status of subgroups such as those who are disadvantaged for reasons of poverty, discrimination or geographic isolation. Ample evidence confirms that children living in poverty suffer adverse health consequences and that the proportion of children living in poverty in the United States has increased steadily since 1975 and dramatically since 1981. Most measures of health status and health risks for children show steady improvements throughout the 1970s. The exercise of public responsibility for financing and providing essential services and supports held constant or improved during this period, especially during the recession of 1974-75. The health status and risks for children since 1981 appear to be adversely affected which must be attributed to a combination of circumstances that include serious recession, increased poverty rates for households with children and diminished health benefits and social support services. These findings suggest that when either local or widespread economic reversals are anticipated, health services and social supports for children need to be expanded rather than contracted.