Evidence of gushing induction by Penicillium oxalicum proteins.

AIMS: The aim of this study was to elucidate whether grape-associated fungi exert an influence on gushing by their production of surface-active compounds. METHODS AND RESULTS: In preliminary experiments, 58 grape-associated isolates of species within Penicillium and Aspergillus genera were tested for their ability to modify the surface activity of culture supernatants. As the genus Penicillium had a higher potential to change surface activity, further research focused on that genus. Subsequently, supernatants of 36 Penicillium isolates were assessed for their potential to induce gushing in a model system. Isolates of Penicillium oxalicum had the highest potential. Different external factors were investigated for their influence on the intensity of gushing. By using reversed-phase high performance liquid chromatography and subsequent MALDI-TOF MS, SDS-PAGE and nano-ESI-LC-MS/MS analysis, two proteins in the exoproteome of P. oxalicum were identified, which could be linked to the induction of gushing. CONCLUSIONS: Our results suggest that infection of grapes by P. oxalicum may contribute to gushing in sparkling wine. SIGNIFICANCE AND IMPACT OF THE STUDY: In contrast to gushing of beer, the reason for its development in sparkling wine is widely unexplored. Nonetheless, sparkling wine producers have also been affected by this economically damaging phenomenon. This study has first suggested about the occurrence of primary gushing in sparkling wine.

Policy evaluation in diabetes prevention and treatment using a population-based macro simulation model: the MICADO model.

AIMS: To test a simulation model, the MICADO model, for estimating the long-term effects of interventions in people with and without diabetes. METHODS: The MICADO model includes micro- and macrovascular diseases in relation to their risk factors. The strengths of this model are its population scope and the possibility to assess parameter uncertainty using probabilistic sensitivity analyses. Outcomes include incidence and prevalence of complications, quality of life, costs and cost-effectiveness. We externally validated MICADO's estimates of micro- and macrovascular complications in a Dutch cohort with diabetes (n = 498,400) by comparing these estimates with national and international empirical data. RESULTS: For the annual number of people undergoing amputations, MICADO's estimate was 592 (95% interquantile range 291-842), which compared well with the registered number of people with diabetes-related amputations in the Netherlands (728). The incidence of end-stage renal disease estimated using the MICADO model was 247 people (95% interquartile range 120-363), which was also similar to the registered incidence in the Netherlands (277 people). MICADO performed well in the validation of macrovascular outcomes of population-based cohorts, while it had more difficulty in reflecting a highly selected trial population. CONCLUSIONS: Validation by comparison with independent empirical data showed that the MICADO model simulates the natural course of diabetes and its micro- and macrovascular complications well. As a population-based model, MICADO can be applied for projections as well as scenario analyses to evaluate the long-term (cost-)effectiveness of population-level interventions targeting diabetes and its complications in the Netherlands or similar countries.

Cost-effectiveness of two endovascular treatment strategies vs intravenous thrombolysis.

OBJECTIVE: To assess the cost-effectiveness of endovascular treatment against intravenous thrombolysis (IVT) when varying assumptions concerning its effectiveness. METHODS: We developed a health economic model including a hypothetical population consisting of patients with ischemic stroke, admitted within 4.5 h from onset, without contraindications for IVT or intra-arterial treatment (IAT). A decision tree and life table were used to assess 6-month and lifetime costs (in Euros) and effects in quality-adjusted life years treatment with IVT alone, IAT alone, and IVT followed by IAT if the patient did not respond to treatment. Several analyses were performed to explore the impact of considerable uncertainty concerning the clinical effectiveness of endovascular treatment. RESULTS: Probabilistic sensitivity analysis demonstrated a 54% probability of positive incremental lifetime effectiveness of IVT-IAT vs IVT alone. Sensitivity analyses showed significant variation in outcomes and cost-effectiveness of the included treatment strategies at different model assumptions. CONCLUSIONS: Acceptable cost-effectiveness of IVT-IAT compared to IVT will only be possible if recanalization rates are sufficiently high (>50%), treatment costs of IVT-IAT do not increase, and complication rates remain similar to those reported in the few randomized studies published to date. Large randomized studies are needed to reduce the uncertainty concerning the effects of endovascular treatment.

Do centres with well-developed protocols, training and infrastructure have higher rates of thrombolysis for acute ischaemic stroke?

BACKGROUND: The introduction of intravenous thrombolysis with recombinant tissue Plasminogen Activator (rt-PA) has greatly improved the effectiveness of acute ischaemic stroke care. However, in most hospitals only 2-10% of all admitted stroke patients are treated with thrombolysis. AIM: The purpose of this study is to identify if available protocols, training and infrastructure influence the thrombolysis rate. DESIGN: Cohort study of 12 hospitals in the Netherlands. METHODS: In a cohort of patients admitted with acute stroke within 24 h from onset of symptoms, data were obtained. Stroke service characteristics of 12 hospitals were acquired through structured interviews with intra- and extramural representatives, in order to asses (i) protocols, (ii) training and (iii) complexity of infrastructure. Data were analysed with multi-level logistic regression to relate the likelihood of treatment with thrombolysis to availability and completeness of protocols, training and infrastructure both outside (extramural) and inside (intramural) each centre. RESULTS: Overall 5515 patients were included in the study. Thrombolysis rates varied from 5.7% to 21.7%. An association was observed between thrombolysis rates and extramural training [odds ratio (OR): 1.11; 95% confidence interval (CI): 0.99-1.25] and availability of intramural protocols (OR: 1.46; 95% CI: 1.12-1.91). After adjustment for hospital size and teaching vs. nonteaching hospital, these associations became stronger; extramural training [adjusted OR (aOR): 1.14; 95% CI: 1.01-1.30] and availability of intramural protocols (aOR: 1.77; 95% CI: 1.30-2.39). CONCLUSIONS: Extramural training and intramural protocols are important tools to increase thrombolysis rates for acute ischaemic stroke in hospitals. Intramural protocols and extramural training should be aimed at all relevant professionals.

Clinical spectrum of patients presenting with bronchiectasis in Nepal: evidence of linkage between tuberculosis, tobacco smoking and toxic exposure to biomass smoke.

AIMS AND OBJECTIVES: The aim of the study was to describe the clinical spectrum of the patients presenting with bronchiectasis at the referral clinic for the respiratory diseases in eastern Nepal. An attempt would also be made to provide an overview of factors responsible for poor lung health in the community. MATERIALS AND METHODS: This is a retrospective observational study conducted at the Adult chest clinic of the department of internal medicine at the B.P Koirala Institute of Health Sciences (BPKIHS), Dharan Nepal. The medical records of all the consecutive patients presenting with the diagnosis of bronchiectasis in the adult chest clinic of department of medicine from January 2003 to December 2004 (two years) were reviewed for patient characteristics (age, gender, place of residence, occupation, smoking history, exposure to indoor air pollution due to use of biomass smoke, past and family history related to tuberculosis, and clinical characteristics such as clinical features and duration of symptoms. RESULTS: During the study period of two years, 100 patients presented with the diagnosis of bronchiectasis, 80 (80%) patients were smokers and 50 (50%) patients had history of significant exposure to indoor air pollution. Abnormal Chest X-ray was seen in 85(85%) patients. Post tubercular bronchiectasis was the most common etiological diagnosis Smoking status and exposure to indoor air pollution were important determinant for hospitalisation in patients with post tubercular bronchiectasis. CONCLUSIONS: In Nepal bronchiectasis remains one of the important chronic respiratory diseases, post tubercular variety being the commonest type. Tuberculosis, tobacco smoking and exposure to indoor air pollution contributes towards higher morbidity of this diseases.

Adapting to changes in molecular biosciences and technologies.

Dental education, like any other educational programme in a research-intensive university environment, must be research led or at least research informed. In this context, as the research and knowledge base of dentistry lies in the biological and physical sciences, dental education must be led by advances in research in both these areas. There is no doubt that biotechnology and nanotechnology have, over the past 25 years, led research in both these areas. It is therefore logical to assume that this has also impacted on dental education. The aim of this paper is twofold; on one hand to examine the effects of biotechnology and nanotechnology and their implications for dental education and on the other to make recommendations for future developments in dental education led by research in biotechnology and nanotechnology. It is now generally accepted that dental education should be socially and culturally relevant and directed to the community it serves. In other words, there can be no universal approach and each dental school or indeed curriculum must apply the outcomes in their own social, cultural and community settings.

Characterization of AfpA, an alkaline foam protein from cultures of Fusarium culmorum and its identification in infected malt.

AIMS: The objective of this study was to evaluate the capability of Fusarium culmorum to produce non-hydrophobin surface-active proteins in vitro, to isolate and characterize such proteins from liquid cultures, to analyse their effect on overfoaming (gushing) of beer and to elucidate their prevalence in pure cultures and infected malt. METHODS AND RESULTS: A 20 kDa protein was isolated from liquid cultures of F. culmorum BBA 62182 upon enrichment by foaming. BLAST search with N-terminal and internal sequences of the protein revealed high homology with a hypothetical protein predicted within the F. graminearum PH1 genome sequence. Oligonucleotide primers designed to bind 30 nt upstream and downstream of the predicted gene were used to amplify a 695 nt PCR fragment from genomic DNA of F. culmorum BBA 62182. Cloning and sequencing of the product revealed a 635 nt open reading frame which had 98% homology to the predicted F. graminearium PH1 gene code. Removal of a 59 nt intron and translation resulted in a 191 amino acid protein of 20.754 kDa with a calculated pI of 9.1. Amino acids obtained by Edman sequencing of fragments within the 20 kDa protein were 100% homologous with the sequence deduced from the DNA sequence. According to its properties, the new protein was termed alkaline foam protein A (AfpA). Sequence comparison revealed some homologies with proteins in Emericella nidulans, which are involved in phialide development and response to antifungal agents. Homologies with other hypothetical fungal proteins suggest a new group of proteins, for which we suggest the name fungispumins. Addition of AfpA to beer showed that overfoaming (gushing) is not induced in stable beer but can significantly enhance this effect in beer showing moderate gushing. Use of a polyclonal anti-AfpA antibody in a Western blot revealed that the protein is produced by various F. culmorum strains and also by F. graminearum, but not by other Fusarium spp. tested. PCR testing of 69 species of Fusarium and Trichoderma reesei with a gene specific primer pair revealed that the gene may be present exclusively in F. culmorum, F. graminearum, F. cerealis, F. lunulosporum and F. oxysporum f. sp . dianthi. Immunochemical detection of AfpA in malts artificially inoculated with F. culmorum and F. graminearum showed that the protein was present in gushing inducing malts (gushing test) but absent in malts which were negative in a gushing test. CONCLUSIONS: AfpA is a member of a new protein class, fugispumins, and can be isolated from pure liquid cultures of F. culmorum. A homologous protein is synthesised by F. graminearum. The protein is produced in contaminated malt and enhances gushing of beer. The gene coding for AfpA is restricted to Fusarium species presumably involved in the induction of beer gushing. SIGNIFICANCE AND IMPACT OF THE STUDY: We describe a new class of proteins, fungispumins, the natural function of which remains to be elucidated. Findings add useful information to research on the mechanisms involved in foam stability of beer. AfpA may be useful as a marker for gushing in future quality control applications for the brewing industry.

Priority setting using multiple criteria: should a lung health programme be implemented in Nepal?

OBJECTIVES: To identify and weigh the various criteria for priority setting, and to assess whether a recently evaluated lung health programme in Nepal should be considered a priority in that country. METHODS: Through a discrete choice experiment with 66 respondents in Nepal, the relative importance of several criteria for priority setting was determined. Subsequently, a set of interventions, including the lung health programme, was rank ordered on the basis of their overall performance on those criteria. RESULTS: Priority interventions are those that target severe diseases, many beneficiaries and people of middle-age, have large individual health benefits, lead to poverty reduction and are very cost-effective. Certain interventions in tuberculosis control rank highest. The lung health programme ranks 13th out of 34 interventions. CONCLUSION: This explorative analysis suggests that the lung health programme is among the priorities in Nepal when taking into account a range of relevant criteria for priority setting. The multi-criteria approach can be an important step forward to rational priority setting in developing countries.

Patient-centred and professional-directed implementation strategies for diabetes guidelines: a cluster-randomized trial-based cost-effectiveness analysis.

AIMS: Economic evaluations of diabetes interventions do not usually include analyses on effects and cost of implementation strategies. This leads to optimistic cost-effectiveness estimates. This study reports empirical findings on the cost-effectiveness of two implementation strategies compared with usual hospital outpatient care. It includes both patient-related and intervention-related cost. PATIENTS AND METHODS: In a clustered-randomized controlled trial design, 13 Dutch general hospitals were randomly assigned to a control group, a professional-directed or a patient-centred implementation programme. Professionals received feedback on baseline data, education and reminders. Patients in the patient-centred group received education and diabetes passports. A validated probabilistic Dutch diabetes model and the UKPDS risk engine are used to compute lifetime disease outcomes and cost in the three groups, including uncertainties. RESULTS: Glycated haemoglobin (HbA(1c)) at 1 year (the measure used to predict diabetes outcome changes over a lifetime) decreased by 0.2% in the professional-change group and by 0.3% in the patient-centred group, while it increased by 0.2% in the control group. Costs of primary implementation were < 5 Euro per head in both groups, but average lifetime costs of improved care and longer life expectancy rose by 9389 Euro and 9620 Euro, respectively. Life expectancy improved by 0.34 and 0.63 years, and quality-adjusted life years (QALY) by 0.29 and 0.59. Accordingly, the incremental cost per QALY was 32 218 Euro for professional-change care and 16 353 for patient-centred care compared with control, and 881 Euro for patient-centred vs. professional-change care. Uncertainties are presented in acceptability curves: above 65 Euro per annum the patient-directed strategy is most likely the optimum choice. CONCLUSION: Both guideline implementation strategies in secondary care are cost-effective compared with current care, by Dutch standards, for these patients. Additional annual costs per patient using patient passports are low. This analysis supports patient involvement in diabetes in the Netherlands, and probably also in other Western European settings.

Molecular detection of ochratoxin A producers: an updated review.

Ochratoxin A (OTA) can be detected worldwide from various food and feed sources. It is produced byPenicillium nordicum andP. verrucosum as well as by variousAspergillus species, withA. ochraceus andA. carbonarius as the predominant producers. Various pairs of PCR primers based on AFLP, RAPD as well as primers specific to ribosomal RNA and genes coding for calmodulin and OTA biosynthetic pathway components were recently developed to detect and identify OTA producers in conventional and real-time PCR assays. Application of such assays in contaminated samples was demonstrated only in few cases. The current review gives an updated overview over the methods at hand.

Changes in utilization of TB health services in Nepal.

SETTING: Nepal. OBJECTIVE: To assess the impact of community mobilization and health worker training on tuberculosis (TB) health services utilization. DESIGN: Questionnaire. METHODS: The Japan International Cooperation Agency and the Nepal Ministry of Health launched a set of interventions to increase awareness and availability of treatment at government facilities. In 2001 and 2003, a questionnaire was administered to TB patients. RESULTS: In 2001-2002, 77.3% of women and 80.0% of men with TB symptoms consulted at government facilities, compared to 30% of men and 32% of women in 1997-1999. CONCLUSION: In the absence of any secular causes, this change can be attributed to the increasing community awareness of availability and quality of DOTS.

Implementing global knowledge in local practice: a WHO lung health initiative in Nepal.

Clinical practice guidelines are used widely to improve the quality of primary health care in different health systems, including those of low-income countries. Often developed at international level and adapted to national contexts to increase the feasibility of effective uptake, guideline initiatives aim to transfer global scientific knowledge into local practice. The WHO's Practical Approach to Lung Health (PAL) is an example of such an initiative and is currently being developed to improve the quality of care for youths and adults with respiratory diseases. We assessed ex-ante the feasibility of successful implementation of PAL in a pilot programme in rural Nepal, studying three components: the quality of the innovation (i.e. the guidelines), the effectiveness of the implementation strategy (i.e. training) and the receptiveness of the social system of health staff at all levels (i.e. social and organizational characteristics). We assessed the guideline innovation with the AGREE instrument for guidelines, the intended implementation strategy by critical comparison with literature on effective strategies, and the social system with both a stakeholder analysis and a descriptive analysis of the health care system at district level. This ex-ante assessment of an adaptive local implementation of international WHO guidelines showed that in July 2002 the 'implementability' of the package was challenged on the three components studied. To increase the chances of successful implementation, the national guideline development process should be improved and the implementation strategy needs to be upgraded. In order to successfully transfer global knowledge into local practice, we need to develop additional multifactorial sustained interventions that tackle other culture-specific and health system-specific barriers as well. The primary health workers are key informants for these barriers.

Advances in the molecular diagnosis of ochratoxin A-producing fungi.

Ochratoxin A (OTA) is detected worldwide in various food and feed sources. The compound is produced by Penicillium nordicum and P. verrucosum, as well as by various species within the sections Nigri and Circumdati of the genus Aspergillus, with A. ochraceus and A. carbonarius known to be the predominant producers. Recently, various pairs of PCR primers based on AFLP, RFLP, RAPD and the calmodulin gene were developed to set up novel diagnostic approaches for OTA producers in the Aspergillus and Penicillium genera. Real-time PCR assays based on well-characterized genomic sequences in A. ochraceus and P. nordicum have also been set up. Since the application of such assays to the analysis of contaminated sample material was demonstrated in only a few cases, future studies should be focused on applying such methods in rapid, robust and user-friendly applications, and implementing them in HACCP concepts. The recent detection and characterization of OTA biosynthetic pathway genes in the Penicillium genus is an important step towards understanding what mechanisms influence production of the toxin in order to redesign production processes in the food and feed industry and to keep de-novo synthesis to a minimum.

Cost-effectiveness of integrated stroke services.

BACKGROUND: Randomized trials have shown that integrating services for acute stroke care may lead to organizational improvements, higher efficiency and better patient outcomes in the acute phase. AIM: To compare the costs and effects of stroke services in an experimental group of patients compared to a group of patients receiving conventional care. DESIGN: Prospective non-randomized controlled trial. METHODS: We compared all consecutively hospitalized stroke patients in three experimental stroke service settings (Delft, Haarlem and Nijmegen, n = 411) with concurrent patients receiving conventional stroke care (n = 187) over 6 months follow-up. Main end-points were total costs per patient and total health-adjusted days per 100 patients as measured by the EuroQol-5D score during follow-up. RESULTS: Mean total costs per patient were 16,000 Euro (95%CI 14,670 Euro-16,930 Euro): 13,160 Euro in Delft, 16,790 Euro in Haarlem, 20,230 Euro in Nijmegen, and 13,810 Euro in the control regions. Early discharge in Delft saved about 2500 Euro hospital costs per patient. General patient health in Delft was significantly better than in the control regions; Haarlem and Nijmegen showed no difference in health. DISCUSSION: Our study confirms the potential to improve stroke outcomes in a cost-effective way in Dutch settings. This was seen in the group of patients in Delft, a complete and relatively simple stroke service, but not in two other regions with more complex stroke services. Important factors are reduction of hospital days and, most likely, adequate multidisciplinary rehabilitation.

Molecular diagnosis of ochratoxinogenicAspergillus species.

Toxigenic and non-toxigenic black aspergilli belonging to theAspergillus niger aggregate and toA. carbonarius were compared to each other and to strains of other species by DNA fingerprinting. AFLPs showed a clear separation ofA. niger andA. carbonarius. However, no clear correlation between the genetic similarity of the strains and the ability to produce ochratoxin A (OTA) was detected. Based on AFLP, marker sequences were chosen for the construction of SCAR-PCR primers for the detection ofA. carbonarius. A similar approach was used forA. ochraceus, another fungus of concern regarding ochratoxin A contamination of coffee. Cluster analysis ofA. ochraceus isolates mainly from Brazilian coffee showed a very close genetic similarity. Three species specific primer pairs were developed and one of these was used for the PCR and realtime PCR (RT-PCR) based detection of the mould in green coffee.A. ochraceus was specifically and rapidly detected and quantified in green coffee. A positive correlation between the amount of DNA and OTA content was established.

Utilization of AFLP markers for PCR-based identification of Aspergillus carbonarius and indication of its presence in green coffee samples.

AIMS: The objective of this work was to test whether ochratoxin A (OTA) production of Aspergillus niger and A. carbonarius is linked to a certain genotype and to identify marker sequences with diagnostic value aiding identification of A. carbonarius, a fungus of major concern regarding OTA production in food and food raw materials. METHODS AND RESULTS: Aspergillus niger and A. carbonarius were isolated mainly from Brazilian coffee sources. The ability of isolates to produce OTA was tested by thin layer chromatography (TLC). Strains were genetically characterized by AFLP fingerprinting and compared with each other and with reference strains. Cluster analysis of fingerprints showed clear separation of A. niger from A. carbonarius strains. To obtain marker sequences, AFLP fragments were isolated from silver stained polyacrylamide gels, cloned and sequenced. Sequences obtained were used to develop species- specific PCR primers for the identification of A. carbonarius in pure culture and in artificially and naturally infected samples of green coffee. CONCLUSIONS: No clear correlation between genetic similarity of the strains studied and their potential to produce OTA was found. The PCR assays designed are a useful and specific tool for identification and highly sensitive detection of A. carbonarius. SIGNIFICANCE AND IMPACT OF THE STUDY: The developed PCR assays allow specific and sensitive detection and identification of A. carbonarius, a fungus considered to be one of the major causative agents for OTA in coffee and grape-derived products. Assays may provide powerful tools to improve quality control and consumer safety in the food processing industry.

An integrated taxonomic study of Fusarium langsethiae, Fusarium poae and Fusarium sporotrichioides based on the use of composite datasets.

An integrated systematic study was carried out to clarify the taxonomical position and relationship of Fusarium langsethiae to other taxa within the Fusarium section Sporotrichiella. Strains of this species were compared with strains of the closely related species Fusarium poae and Fusarium sporotrichioides using a composite dataset. This set consisted of DNA sequences derived from the ribosomal internal transcribed spacer (ITS) regions, partial sequences of the ribosomal intergenic spacer (IGS) region, the beta-tubulin and translation elongation factor-1 alpha (EF-1alpha) genes, AFLP fingerprints, chromatographic data on secondary metabolites and morphological data and growth characteristics. From these combined data, a consensus matrix was calculated by taking the mean of all pairwise distances between single isolates over all separate datasets. The consensus matrix was used as the basis for the construction of a UPGMA dendrogram and a multidimensional scaling, both of which revealed a clear separation of the three taxa. Partial IGS, EF-1alpha and beta-tubulin sequence-as well as chromatography-and AFLP-derived similarities turned out to be comparably consistent, while ITS sequence- and morphology-derived similarity matrices were rather divergent.

Detection and quantification of Aspergillus ochraceus in green coffee by PCR.

AIMS: The aim of this study was to detect and quantify DNA of the ochratoxinogenic fungus Aspergillus ochraceus in green coffee and to compare the results with the ochratoxin A content of naturally contaminated samples. METHODS AND RESULTS: A DNA extraction protocol based on a combination of ultrasonification and a commercial kit was tested for the recovery of fungal DNA. PCR and real-time PCR protocols were established for the detection of A. ochraceus. Sensitivity of the PCR was checked by the addition of inoculated green coffee and pure fungal DNA to uncontaminated green coffee samples. The A. ochraceus DNA content of 30 naturally contaminated green coffee samples was determined and compared with the ochratoxin A concentrations. CONCLUSIONS: Aspergillus ochraceus can be rapidly and specifically detected in green coffee by PCR. A positive correlation between the ochratoxin A content and the DNA quantity was established. SIGNIFICANCE AND IMPACT OF THE STUDY: This work offers a quick alternative to the conventional mycological detection and quantification of A. ochraceus in green coffee.

Cost-effectiveness of glycemic control and ophthalmological care in diabetic retinopathy.

AIMS: Glycemic control and ophthalmological care are known to significantly diminish the risk of visual impairment and blindness by diabetic retinopathy (DRP). The (cost-)effectiveness of both strategies was studied to highlight their benefits for patients and care providers. METHODS: A computer analysis was developed, following the progression of DRP and the effectiveness of metabolic control and ophthalmological care continuously and individually in cohorts of type I and type II DM patients with divergent degrees of compliance. Costs relate to present medical charges in the Netherlands. RESULTS: Intensive glycemic control shortens the duration of blindness in a type I DM patient by 0.76 years, intensive ophthalmological care by 0.53 years. One year sight gain may cost 1126 euros by providing ophthalmological care and 50479 euros by glycemic control. The duration of blindness drops in a type II DM patient by 0.48 and 0.13 years, respectively, whereas the effectiveness decreases as the age of onset of DM rises. CONCLUSIONS: The vast majority of diabetic patients benefits from both intensive glycemic control and intensive ophthalmological care, but these cost-effective interventions which are not only complementary, but also substitute each other, require lasting, full compliance by all parties concerned.