Phylogenetic Analysis of Mycobacterium tuberculosis Strains in Wales by Use of Core Genome Multilocus Sequence Typing To Analyze Whole-Genome Sequencing Data.

An inability to standardize the bioinformatic data produced by whole-genome sequencing (WGS) has been a barrier to its widespread use in tuberculosis phylogenetics. The aim of this study was to carry out a phylogenetic analysis of tuberculosis in Wales, United Kingdom, using Ridom SeqSphere software for core genome multilocus sequence typing (cgMLST) analysis of whole-genome sequencing data. The phylogenetics of tuberculosis in Wales have not previously been studied. Sixty-six Mycobacterium tuberculosis isolates (including 42 outbreak-associated isolates) from south Wales were sequenced using an Illumina platform. Isolates were assigned to principal genetic groups, single nucleotide polymorphism (SNP) cluster groups, lineages, and sublineages using SNP-calling protocols. WGS data were submitted to the Ridom SeqSphere software for cgMLST analysis and analyzed alongside 179 previously lineage-defined isolates. The data set was dominated by the Euro-American lineage, with the sublineage composition being dominated by T, X, and Haarlem family strains. The cgMLST analysis successfully assigned 58 isolates to major lineages, and the results were consistent with those obtained by traditional SNP mapping methods. In addition, the cgMLST scheme was used to resolve an outbreak of tuberculosis occurring in the region. This study supports the use of a cgMLST method for standardized phylogenetic assignment of tuberculosis isolates and for outbreak resolution and provides the first insight into Welsh tuberculosis phylogenetics, identifying the presence of the Haarlem sublineage commonly associated with virulent traits.

Sepsis programme successes are responsible for the increased detection of bacteraemia.

BACKGROUND: Escherichia coli bacteraemia reduction targets are challenging but, in West Wales, this was the key infection surrogate measure set by the local health board in 2013, prior to the introduction of a Welsh Government target. The initial plateau of cases was not maintained and prompted this review. AIM: To review all blood cultures submitted between 2002 and 2016, both positive and negative. METHODS: With access to a microbiology data warehouse in Wales, all blood culture results were collected, extracted to Excel tables and analysed using change point analysis. FINDINGS: Just under 200,000 blood culture results were examined. This study found an increase in blood culture submissions, but the positivity rate remained constant throughout the period and the increased number of E. coli reflected the increased number of blood cultures taken. This demonstrated the success of sepsis awareness and the use of sepsis bundles for rapid diagnosis and management. CONCLUSION: Success in one area (sepsis management) conflicts with 'failure' in reducing E. coli bacteraemia. It is argued that targets need to be considered carefully in the light of all available information, which have currently set the National Health Service up to fail.

Use of epidural clonidine for the management of analgesia in the opioid addicted parturient on buprenorphine maintenance therapy: an observational study.

OBJECTIVES: Management of labor analgesia and post-cesarean delivery pain is challenging in the patient taking buprenorphine as opioid addiction maintenance therapy. We observed whether substituting clonidine for fentanyl in an epidural solution would provide adequate analgesia for labor and after cesarean delivery. METHODS: We substituted our standard 2 µg/mL fentanyl in 0.0625% bupivacaine epidural solution with 2 µg/mL clonidine in 0.0625% bupivacaine, or 1.2 µg/mL clonidine in 0.1% bupivacaine, for labor and post-cesarean analgesia in parturients on buprenorphine therapy. All cesarean deliveries were performed with a combined spinal-epidural technique and the catheters maintained for immediate postoperative analgesia using an epidural infusion. Catheters were discontinued the next day and patients were then managed with other analgesics based on obstetric preference. We recorded pain scores during labor and in the immediate post-surgical period; and supplemental medications given after epidural catheter removal. RESULTS: Fourteen patients were included in the study, of whom seven presented in spontaneous labor and seven had elective cesarean delivery. All laboring patients achieved good analgesia, and five of seven avoided supplemental opioid use in the postpartum phase. Of the postsurgical patients, six of seven had pain scores less than 5/10 at epidural catheter removal and three of seven avoided supplemental opioids postoperatively. CONCLUSIONS: The combination of clonidine and bupivacaine appears effective in parturients on buprenorphine therapy for opioid addiction maintenance. As study numbers were small and several factors were not examined, further confirmatory research is needed, including to determine the ideal dose of epidural clonidine in this setting.

Gonadal function is associated with cardiometabolic health in pre-pubertal boys with Klinefelter syndrome.

The most common sex chromosome aneuploidy, Klinefelter syndrome (KS), is associated with primary gonadal failure and increased morbidity and mortality from cardiometabolic disorders in adulthood. Children with KS also have a high prevalence of metabolic syndrome (MetS) features. To assess the relationship of gonadal and cardiometabolic function in children with KS, we evaluated serum hormones [gonadotropins, inhibin B (INHB), anti-mullerian hormone (AMH), total testosterone (TT)], and features of MetS (waist circumference, fasting lipid panel, fasting blood glucose (FBG), and blood pressure) in 93 pre-pubertal boys with KS age 4-12 years (mean 7.7 ± 2.5 years). The cohort was grouped by age and tanner stage, and biomarkers were compared to normal ranges. A total of 80% of this pre-pubertal cohort had ≥1 feature of metabolic syndrome (MetS) and 11% had ≥3 features of MetS. Risk of MetS was independent of age and body mass index. Sertoli cell dysfunction was common with 18% having an INHB below the normal range. A low INHB was associated with higher FBG, triglycerides, LDL, and lower HDL (p < 0.05). An INHB <50 ng/dL yielded a sensitivity of 83% and a specificity of 79% for having ≥3 features of MetS. INHB and AMH positively correlated with each other (p < 0.001), and high AMH was protective of MetS. TT was below the lower limit of normal in 49% of subjects, with mean values significantly lower than expected (3.3 ng/dL vs. 4.9 ng/dL, p < 0.0001), however, no convincing relationship between TT and MetS was seen. In conclusion, gonadal and cardiometabolic dysfunction are prevalent in pre-pubertal boys with KS. Although the relationship of testosterone deficiency and MetS is well-known, this study is the first to report an association between impaired Sertoli cell function and cardiometabolic risk.

Audit of a network of sexually transmitted infections centred in South Wales.

The aim of this article is to audit the distribution and frequency of sexually transmitted infections (STIs) within a sexual network centred in South Wales. After diagnosis of a new case of HIV in February 2007, partner notification, HIV and STI testing were undertaken. Those traced were given information regarding safe sex practices and informed they had been in contact with HIV. Genitourinary (GU) medicine case-notes of contacts identified in the network were reviewed from February 2007 to 1 July 2008. Frequency and distribution of new diagnoses of STIs made on original identification in the network in 2007 were compared with subsequent new diagnoses within the network. One hundred and eighteen men who have sex with men (MSMs) and five women were identified in the original network in 2007. By 1 July 2008, 65 new sexual contacts (all MSMs) were added to the network and there were 25 new STI diagnoses in 13 contacts. Seven contacts originally identified in the cluster in 2007 were diagnosed with 16 of the new STIs. In conclusion, the sexual network has evolved by increasing in size with multiple new STIs diagnosed. The highest risk of STIs occurred in relatively few individuals. Standard interventions in health promotion in the GU medicine setting were not universally successful in preventing high-risk behaviour.

Investigation of an HIV transmission cluster centred in South Wales.

OBJECTIVE: To describe an HIV transmission cluster centred in South Wales by the analysis of partner notification outcomes and demographic characteristics of individuals identified in the sexual network. METHODS: After diagnosis of the index case, HIV testing and partner notification were undertaken by Cardiff Genitourinary Medicine Clinic in collaboration with the local Health Protection Team, National Public Health Service for Wales and Terrence Higgins Trust Cymru. Rapid test and standard venepuncture methods were used for HIV screening and the resulting clinical and behavioural data were analysed. RESULTS: Of the 123 individuals identified in the sexual network, all were men who had sex with men (MSM) except for seven men who self-identified as bisexual and five heterosexual women. Fifteen new cases of HIV were diagnosed; all were men. Partner notification outcomes are as follows: 104 provider referrals were made, 57 were successfully contacted with known outcomes, 14 were successfully contacted but with unknown outcomes and 33 were uncontactable. Fifteen patient referrals were made, 11 had known outcomes but four had unknown outcomes. Four patients self-referred. Eleven reported previous HIV diagnosis. The sexual network was distributed over South and West Wales extending into England, with high reported rates of unprotected anal intercourse, previous HIV tests and concurrent sexually transmitted infections. A one in four positive rate for those with a known HIV status outcome and a 68% provider referral success rate compares favourably with other studies. CONCLUSIONS: Partner notification revealed a relatively young, well-educated HIV network with high-risk behaviour and ongoing transmission despite previous knowledge and awareness of HIV. This analysis adds to the evidence supporting HIV partner notification in MSM.

Does tonsillectomy lead to improved outcomes over and above the effect of time? A longitudinal study.

OBJECTIVE: To determine the effect of tonsillectomy on morbidity in patients listed for tonsillectomy. DESIGN: Questionnaire survey of 257 children and 159 adults who had been listed for tonsillectomy. The cohort studied had experienced delays of greater than 12 months between being listed for tonsillectomy and undergoing surgery. They had responded to an earlier questionnaire in 2003 regarding morbidity experienced while waiting for surgery. The same questionnaire was presented to them again in 2005. Morbidity experienced in 2003 was compared to that experienced in 2005 in subjects who had and had not proceeded to surgery in the interval. RESULTS: Forty-seven per cent of the cohort had undergone tonsillectomy. The questionnaire response rate was 48 per cent. Respondents reported less morbidity in 2005 than in 2003, whether or not they had had surgery. Respondents who had undergone tonsillectomy reported significantly greater reductions in morbidity than those who had not. Five per cent of children who had undergone tonsillectomy experienced at least three short episodes of tonsillitis in the six months before the questionnaire, compared with 35 per cent of those who had not undergone tonsillectomy (p < 0.001). CONCLUSIONS: The morbidity reported by patients suffering from chronic, untreated tonsillitis decreases with time. Tonsillectomy produces significantly greater reductions in morbidity than time alone.

Age- and site-associated biomechanical weakening of human articular cartilage of the femoral condyle.

OBJECTIVE: To determine the time sequence of biochemical and structural events associated with, and hypothesized to underlie, age-associated tensile weakening of macroscopically normal adult human articular cartilage of the knee. METHODS: Macroscopically normal human articular cartilage of the lateral and medial femoral condyles (LFC and MFC) from Young (21-39 yrs), Middle (40-59 yrs), and Old (>/=60 yrs) age donors were analyzed for tensile properties, surface wear, and cell and matrix composition. RESULTS: Variations in tensile, compositional, and surface structural properties were indicative of early, intermediate, and late stages of age-associated cartilage deterioration, occurring at an earlier age in the MFC than the LFC. Differences between Young and Middle age groups (indicative of early-to-intermediate stage changes) included decreased mechanical function in the superficial zone, with a loss of (or low) tensile integrity, and surface wear, with faint striations and mild staining on the articular surface after application of India ink. Differences between Middle and Old age groups (indicative of intermediate-to-late stage changes) included maintenance of moderate level biomechanical function, a decrease in cellularity, and a decrease in matrix glycosaminoglycan content. Tissue fluorescence increased steadily with age. CONCLUSIONS: Many of these age-associated differences are identical to those regarded as pathological features of cartilage degeneration in early osteoarthritis. These findings provide evidence for the roles of mechanical wear, cell death, and enzymatic degradation in mediating the progression through successive and distinguishable stages of early cartilage deterioration.

Effects of dose and duration of continuous GnRH-agonist treatment on induction of estrus in beagle dogs: competing and concurrent up-regulation and down-regulation of LH release.

Dose-response estrus-induction trials were conducted during anestrus in 93 treated and 6 control bitches, a continuous administration of the GnRH-agonist lutrelin with a potency 150 x GnRH, and at six different doses from 0.2 to 4.8 microg/kg/d for 7-14 days in 15 groups of six to eight dogs each in defined stages of natural or pharmacologically determined anestrus. Agonist treatment induced clinically and cytologically normal proestrus (in 89% of cases) within 4.8 +/- 0.2 x days, and resulted in behavioral estrus (71%), spontaneous late-proestrus LH (and FSH) surges, ovulation (59%) and pregnancy (44%) in a dose dependent manner. Outcomes of ovulation and pregnancy in most cases required that the dose be sufficiently large enough to routinely stimulate a large initial increase in LH and FSH (i.e., > or = 0.6 microg/kg/d), and of sufficient duration (i.e., > 7 days) to ensure that supra-basal gonadotropin levels persistedntil no longer needed for spontaneous continuation of an induced proestrus. Success additionally required that the GnRH dose be modest enough (i.e., < 1.8 microg/kg/d) to not excessively down-regulate spontaneous pre-ovulatory surge release of gonadotropin or be removed shortly before or at the time when the LH surges typically occurred (10-13 days after initiation of treatment). The 1.8 microg dose was compared to saline to assess the time course of its down-regulation action on serum LH in six ovariohysterectomized bitches compared to four saline-related controls. Results in intact bitches receiving the 1.8-microg doses demonstrated an LH-releasing effect for 10-11 days that overlapped a period of obvious down-regulation seen with the same dose after 3 days in the ovariohysterectomized bitches. In the latter, however, complete down-regulation to anestrus-like values did not occur until after 18-21 days of treatment. A dose of 0.6 microg/kg/d for 12 days yielded the best estrus-induction results, including pregnancy rates of 100% in six bitches treated in natural-anestrus bitches, six bitches in which anestrus had been advanced by a luteolytic prostaglandin treatment and in six bitches in which anestrus had been extended by progesterone implants administered for 3 months. Although lutrelin is not commercially available, these results provide guidelines for the development of estrus-inducing protocols with other GnRH-agonists of known biopotencies.

Instrumentation and patient characteristics that influence postoperative haemorrhage rates following tonsil and adenoid surgery.

OBJECTIVES: To investigate the effect of the type instrumentation used and the age and gender characteristics of patients on postoperative haemorrhage rates following tonsil and adenoid surgery. DESIGN: A retrospective analysis of 13 593 procedures was performed from The Patient Episode Database for Wales between 1 January 1999 and 31 March 2004. SETTING: National health policy changes created four periods of different instrument usage (reusable, single-use with diathermy, single-use alone, specified single-use with diathermy). These and the age and gender distribution of the patients were examined against four categories of postoperative haemorrhage. MAIN OUTCOME MEASURES: Postoperative haemorrhage rates were expressed as the number of complications per operations performed. Primary postoperative haemorrhage that occurred during the initial admission either required a return to theatre [R1] or was managed conservatively [N1]; secondary postoperative haemorrhage that required a return to hospital either returned to theatre [R2] or was managed conservatively [N2], were compared. RESULTS: Primary haemorrhage with return to theatre doubled, from the baseline rate with reusable instruments, from 0.6% (CI 0.5-0.8) to 1.2% (CI 0.7-1.9) when single-use instruments were introduced and remained high at 1.4% (CI 0.9-2.1) after the withdrawal of single-use diathermy. This haemorrhage rate returned to the baseline rate (0.6% CI 0.3-1.0) when specified single-use instruments were introduced. None of the other haemorrhage rates changed significantly throughout the four observation periods. Adenotonsillectomy and tonsillectomy patients have different age and gender patterns. In a univariate analysis, males over the age of 12 years were twice as likely to have haemorrhage with return to theatre than girls of the same age, 3.8% (CI 3.0-4.7) versus 1.7% (CI 1.4-2.1). CONCLUSIONS: A significant rise in serious postoperative primary haemorrhage but not secondary haemorrhage was seen following the initial introduction of single-use instruments that reverted to baseline with the introduction of specified single-use instruments. Diathermy does not appear to have affected the haemorrhage rates. There is a distinct age and gender pattern for tonsil and adenoid surgery and risk of postoperative haemorrhage. The use of arbitrary divisions of age may be misleading in studies that examine post-tonsillectomy haemorrhage.

A laboratory and clinical evaluation of single-use instruments for tonsil and adenoid surgery.

OBJECTIVES: To compare the quality and consistency of single-use adenotonsillectomy instruments available in the UK with reusable instruments and examine their performance in a clinical setting. DESIGN: A laboratory assessment of each reusable instrument created a detailed specification for the respective single-use equivalent. A surveillance system monitored the performance of a selected set of specified single-use instruments. SETTING: Single-use instruments were withdrawn shortly after their introduction in 2001. Persisting concerns from the Spongiform Encephalopathy Advisory Committee led to an investigation into the feasibility of continuing to use such instruments. MAIN OUTCOME MEASURES: The numbers of instruments from each set judged as unacceptable or as good as the original. The number and cause of instrument failure during clinical surveillance. RESULTS: Between 40% and 93% of the instruments on each set were as good as the original and between 0% and 40% of the instruments were unacceptable from six sets of steel and one set of polymer instruments. 4151 procedures were monitored between 1 February 2003 and 31 March 2004 using a total of 41 376 instruments. Problems were reported with 335 (0.8%) instruments, 46% attributable to instrument design, 14% to poor design control and 13% to instruments escaping quality control systems. Following correction of the faults, between 1 January 2004 and 31 March 2004 the problem rate fell to 0.4%. CONCLUSIONS: High quality single-use instruments for tonsil and adenoid surgery are available in the UK. Some companies offered inferior instruments not fit for their purpose. The procurement, introduction and subsequent clinical approval of single-use instruments requires a radically different approach to that currently applied to the purchase of reusable surgical equipment. Careful monitoring of their introduction is essential.

Early detection of prostate cancer in the ESRD population.

BACKGROUND: There are currently no prostate cancer screening guidelines specific to the end-stage renal disease (ESRD) population. With this in mind, we evaluated the clinical usefulness of digital rectal examination (DRE), serum total prostate-specific antigen (PSA), prostate-specific antigen density (PSAD) and transrectal ultrasound (TRUS) in predicting prostate cancer in men with ESRD. METHODS: Fifty male ESRD patients age 40 years and older with no prior history of prostate cancer were enrolled in the study. All patients underwent PSA measurement and a DRE followed by a TRUS. PSAD was calculated as the total PSA divided by the prostate volume. Ultrasound-guided prostate biopsies were performed on any patient with 1 or more of the following abnormal findings: a nodule detected on DRE; an abnormal TRUS; PSA > 4.0 ng/ml, or a PSAD > 0.15 ng/ml/cm3. RESULTS: Abnormal findings were detected in 19 patients. Two (4%) had an abnormal DRE, 3 (6%) had PSA > 4.0 ng/ml, 3 (6%) had PSAD > 0.15 ng/ml/cm3 and 16 (32%) had abnormal findings on TRUS. Three patients had 2 abnormal findings and 1 had 3. Of the 15 prostate biopsies performed, 4 (27%) revealed prostate cancer and 3 (20%) high-grade prostatic intraepithelial neoplasm (HGPIN) comprising 8% and 6%, respectively, of the studied population. Of the 4 patients diagnosed with prostate cancer, none had abnormal DRE, 2 (50%) had PSA > 4.0 ng/ml (sensitivity = 66.7% and PPV = 50% (p = 0.236)), 3 (75%) had PSAD > 0.15 ng/ml/cm3 (sensitivity = 100% and PPV = 75% (p < 0.018)), and 3 (75%) had abnormal findings on TRUS (sensitivity = 30% and PPV = 75% (p = 1.000)). CONCLUSION: Routine screening with PSA and DRE does not seem sensitive enough to predict the presence of the disease. Although TRUS detected abnormalities in 16 patients (32%), sensitivity was very low (30%). In our patients, PSAD increased the sensitivity and positive predictive value (PPV) of detecting prostate cancers compared to PSA alone.

A prospective, longitudinal study of central venous catheter-related deep venous thrombosis in boys with hemophilia.

BACKGROUND: Central venous catheters (CVCs) are often inserted into boys with hemophilia to secure venous access for factor prophylaxis and immune tolerance induction therapy. Complications associated with CVCs include catheter-related infections, local hemorrhage, and mechanical failure. Less frequently reported is CVC-related deep venous thrombosis (DVT). We conducted a prospective study to determine the frequency and outcome of this complication. METHODS: All boys (n = 16) with congenital hemophilia A or B with a CVC in place who were registered in the pediatric comprehensive care program at the Hospital for Sick Children, Toronto, were included in the study. They were prospectively assessed by imaging studies and clinical examinations for CVC-related DVT at two time-points, 2 years apart. Each boy was evaluated for inherited hypercoagulability. RESULTS: Eleven (69%) of the 16 boys had radiological evidence of DVT at the first evaluation and 13/16 (81%) at the second evaluation. In two boys there was improvement in the venogram findings at the second evaluation. None of the CVC-related DVTs completely resolved. Median age at the time of initial insertion of a CVC was 1.0 years (range 0.02-6.7 years). Median duration of CVC placement was 6.4 years (range 3.3-15.5 years). Only 4/13 boys with DVTs had clinical evidence of upper venous system obstruction. Only one boy, who did not develop a DVT, had a low protein C level. CONCLUSIONS: CVC-related DVTs occur in the majority of boys with hemophilia who have CVCs inserted for a prolonged period of time. Annual screening with imaging is recommended for boys with CVCs in place for >/= 3 years. Consideration should be given to removing CVCs as soon as peripheral venous access is feasible.

Rapid collaborative health impact assessment: a three-meeting process.

A three-meeting process for collaborative health (inequality) impact assessment [H(I)IA] of a proposed new road is described in which local residents worked with professionals to produce a jointly agreed evidence-based report. Collaborative H(I)IA provided a forum for people to express fears that they believed had been ignored, and for planners to understand the concerns of the community and the health impacts of developments on the most vulnerable. The report has been passed to those who will influence the future of the road development plan and a decision is awaited.

Use of atypical anti-psychotics in the management of post-traumatic confusional states in traumatic brain injury.

The use of atypical anti-psychotics (AAP) in the treatment of organic neuropsychiatric syndromes is little reported. We present a case of post-traumatic delirium with delusions treated with Risperidone and discuss the use of AAP's in this situation.

A priori assessment of the stereoelectronic profile of phosphines and phosphites.

This research has demonstrated the utility of a rigorously calibrated, molecular mechanics/semiempirical quantum mechanical protocol for developing stereoelectronic (Tolman) maps for phosphine ligands. A computational analysis of alkyl and aryl phosphines in common usage suggests that these ligands are quite similar stereoelectronically. A noticeable gap in the Tolman map for common phosphines is observed for large, electron-poor phosphines. Several candidates meeting these criteria were identified, the most promising of which is P(t-C(4)F(9))(3). Phosphines in which the phosphorus participates in a ring, which comprise a very small subset of reported phosphines, have very interesting stereoelectronic properties, particularly those in which the ligating phosphorus is part of a three-membered ring. In terms of steric properties, the symmetric deformation coordinate proposed by Orpen and co-workers on the basis of crystallographic studies is calculated with sufficient accuracy using PM3(tm) to allow good confidence in predictions of novel phosphines. For quantification of the electronic properties of phosphines, we analyzed changes in the CO stretching frequency upon changing the ancillary phosphine ligands.