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Primary Human Papillomavirus (HPV) screening on samples collected by women themselves has proven to be an effective strategy for cervical cancer screening (CCS) and may increase participation rates in women who do not partake (regularly) in screening. The aim of this study is to investigate reasons for non-participation and perceptions of CCS using self-sampling methods among under-screened women in Flanders. Individual interviews with 15 underscreened women aged 30–64 years were conducted. During the interviews, participants were given the opportunity to try out a urine and vaginal self-sampling kit. Thematic analysis was based on Ajzen’s model of the Theory of Planned Behavior. The results showed that 14 out of 15 participants were more likely to participate in CCS if they had the option to self-sample. One of the main findings was a lack of knowledge on different aspects of cervical cancer. Most women had a positive attitude toward cancer screening and primary prevention such as HPV vaccination. Subjective norms were influenced by healthcare professionals, peers, and organized government initiatives. Informational, organizational, contextual, and emotional factors were mentioned as barriers as well as facilitators for participation. Additionally, high self-efficacy was considered to make self-sampling more convenient. All women showed the intention to use at least one method of self-sampling. We can conclude that women who do not participate in CCS would be more motivated to participate using self-sampling methods. Adequate education and guidance should be provided.

This study explores the establishment experiences of physicians in the Swedish medical context who have been trained outside the European Union. The study used a qualitative approach with a quasi-longitudinal research design. The data were gathered via 63 semi-structured interviews with migrant physicians at three different periods. The data were analysed using qualitative thematic content analysis, adopting the theory on the context dependence of knowledge, which includes different forms of knowledge as sensitising concepts in the discussion. The MPs perceived themselves as having the medical knowledge (encoded knowledge) needed to work in Sweden. However, they perceived that they needed to develop knowledge of how to use the encoded knowledge in the Swedish medical context. The needed knowledge was thus foremost encultured, embedded, embodied, or embrained. The results are presented in the following themes: medical knowledge; knowledge of the healthcare system and its variations; knowledge of administrative routines; understanding the role as a physician, interaction and hierarchies between physicians and other healthcare staff; understanding the interaction and hierarchies between physicians and patients; and knowledge of the Swedish language. Knowledge, as described in the themes, function as gateways that needs to be unlocked for practising medicine in a new context. Embedded, embrained, embodied, and encultured knowledge interact and are interdependent, and the different forms of knowledge work as gateways to other forms of knowledge, and thus, they open for each other. However, to pass the gateways, managing the common language is important. We conclude that language is an enabler and a key to unlocking gateways to practise.

Mycobacterium avium subsp. paratuberculosis (MAP) is the etiological agent of Johne’s disease, a severe gastroenteritis of ruminants. This study developed a model cell culture system to rapidly screen MAP mutants with vaccine potential for apoptosis. Two wild-type strains, a transposon mutant, and two deletion mutant MAP strains (MOI of 10 with 1.2 × 106 CFU) were tested in murine RAW 264.7 macrophages to determine if they induce apoptosis and/or necrosis. Both deletion mutants were previously shown to be attenuated and immunogenic in primary bovine macrophages. All strains had similar growth rates, but cell morphology indicated that both deletion mutants were elongated with cell wall bulging. Cell death kinetics were followed by a real-time cellular assay to measure luminescence (apoptosis) and fluorescence (necrosis). A 6 h infection period was the appropriate time to assess apoptosis that was followed by secondary necrosis. Apoptosis was also quantified via DAPI-stained nuclear morphology and validated via flow cytometry. The combined analysis confirmed the hypothesis that candidate vaccine deletion mutants are pro-apoptotic in RAW 264.7 cells. In conclusion, the increased apoptosis seen in the deletion mutants correlates with the attenuated phenotype and immunogenicity observed in bovine macrophages, a property associated with good vaccine candidates.

Little is known about the role that B cells play in immune responses to infection with the intracellular pathogen, Mycobacterium avium subsp. paratuberculosis (MAP). Traditionally, the role of B cells has been constrained to their function as antibody-producing cells, however, antibodies are not thought to play a protective role in mycobacterial infections. The present study was designed to characterize B cell subpopulations as well as activation/maturation states in cattle with paratuberculosis. Peripheral blood mononuclear cells (PBMCs) were isolated from noninfected control cows (n = 8); as well cattle naturally infected with MAP in the subclinical (n = 8) and clinical (n = 7) stage of infection and stimulated with MAP antigen for 6 days. MAP infection resulted in greater numbers of total B cells for clinical cows compared to control noninfected cows. The major subpopulation in freshly isolated PBMCs in clinical cows was B-1a B cells, but this shifted to a composite of both B-1a and B-2 B cells upon stimulation of PBMCs with either MAP antigen or pokeweed mitogen, with higher numbers of B-2 B cells. Early B cells were observed to predominate the population of B cells in PBMCs, with lesser populations of germinal B cells, memory B cells and plasma cells. These subpopulations were elevated in clinical cows upon stimulation of PBMCs with MAP antigen, except for plasma cells which were lower compared to control noninfected cows. Increased numbers of B cells in clinical cows aligned with higher expression of B cell markers such as MAPK1/3, BTG1, Bcl2, CD79A and SWAP70, depending upon in vitro stimulation with either mitogen or antigen. This would indicate that the B cells were capable of activation but were anti-apoptotic in nature. The shift to B-2 B cells in the periphery of clinical cows seems to be indicative of an expansion of memory B cells, rather than plasma cells. This may be a last attempt by the host to control the rampant inflammatory state associated with advanced clinical disease.

Background The Danish Physiotherapy Research Database for chronic patients receiving Free of Charge Physiotherapy (PhysDB-FCP) was piloted over a 1-year period. The purpose of the PhysDB-FCP is to provide a user friendly digital online structured tool that standardizes initial and follow up clinical assessments generating data that can be used for clinical decision making and support future research in physiotherapy for patients with chronic disease. Although initial assessments were completed, the attrition rate was 73% and 90% at 3- and 6- months, respectively, which suggests problems with the current tool. Objective To evaluate the perspectives of the physiotherapists that used the PhysDB-FCP and propose changes to the tool based on this feedback. Materials and methods Fifty of the 103 physiotherapists introduced to the PhysDB-FCP completed an anonymous online survey. Physiotherapists were asked Likert/categorical and yes/no questions on experiences with the PhysDB-FCP within their practice, perceptions of patient experiences, suitability of the resources and support provided by the PhysDB-FCP working group and the ideal administration frequency of the assessments within the PhysDB-FCP. Open ended feedback on possible improvements to the PhysDB-FCP was also collected. Results Physiotherapists agreed that the PhysDB-FCP was useful for taking a physiotherapy assessment (74%) and the patient survey was useful for goal setting (72%). Although physiotherapists felt the PhysDB-FCP was well-defined (82%), only 36% would like to use a similar tool again. Generally, the PhysDB-FCP was too time-consuming, administered too frequently and included irrelevant items. For example, 72% of physiotherapists took >45 min to administer the assessment in the first consultation which was performed over multiple sessions. Conclusions The perspectives of physiotherapists using The PhysDB-FCP suggest specific changes that will ensure better use of the tool in future practice. Changes will likely involve administering the assessment less frequently (every 6-months to 1-year), shortening the assessment, and using diagnosis-specific assessment items.

Johne’s disease affects ruminants causing an economic burden to dairy, meat and wool industries. Vaccination against Mycobacterium avium subspecies paratuberculosis (Map), which causes Johne’s disease, is a primary intervention for disease control in livestock. Previously, a comprehensive, multi-institutional vaccine trial for Johne’s disease was conducted to test the efficacy of live attenuated Map strains. Here, we report the humoral and cell-mediated immune responses from kid goats enrolled in that trial. Both vaccinated and unvaccinated animals showed IFN-γ stimulation and proliferation of T cell subpopulations on challenge with Map. CD4+, CD25+ and γδ cells from cultured PBMCs in the vaccinated goats showed significantly greater proliferation responses on stimulation with Map antigens. The increase in CD44+ and decrease in CD62L+ cells suggest that vaccine administration reduced the inflammatory responses associated with Map infection. Overall, a stronger antibody response was observed in the infected goats as compared to vaccinated goats. Two independent experimental approaches were used to identify differences in the antibody responses of vaccinated and unvaccinated goats. The first approach involved screening a phage expression library with pooled serum from infected goats, identifying previously reported Map antigens, including MAP_1272c and MAP_1569. However, three specific antigens detected only by vaccinated goats were also identified in the library screens. A second approach using dot blot analysis identified two additional differentially reacting proteins in the vaccinated goats (MAP_4106 and MAP_4141). These immunological results, combined with the microbiological and pathological findings obtained previously, provide a more complete picture of Johne’s disease control in goats vaccinated against Map.

Abstract Objectives Mycobacterium avium subspecies paratuberculosis (MAP) causes Johne’s disease in ruminants. The “gold standard” of MAP detection is by culture, DNA sequencing possibly supplemented by identification of Ziehl–Neelsen positive mycobacteria. The purpose of this study was to evaluate a proprietary (Affymetrix™ RNA view®) fluorescent in situ hybridization (FISH) assay for MAP RNA. Intestine from a steer with documented Johne’s disease was assayed according to the manufacturer’s instructions. Probes were custom designed for MAP and bovine β-actin (as the eukaryotic housekeeping gene) from published genomes. We attempt to prevent false positive signal in the “no-probe” control, by modifying wash solutions, using recommended hydrochloric acid titration and different fluorescent filters (TritC for Texas Red and “Hope” for Cy-5). Results Repetitively, false positive signal was observed in our “no probe” negative control. Attempts to correct this according to the manufacturers suggestions, and with multiple derivative techniques have been unsuccessful. It is concluded that when performed according to manufactures instruction and with multiple variations on the manufactures recommended suggestions to correct for false positive signal, that the Affymetrix™ RNA view® cannot be used to detect MAP in pre-frozen intestine of cattle with Johne’s disease.

Macrophages play an important role in the host immune response to Mycobacterium avium subsp. paratuberculosis (MAP) infection, however, MAP is able to disrupt normal macrophage functions to avoid destruction. It is unclear whether the phenotypes of macrophages present in the target tissue play a role in the inability to clear MAP infection. The aim of this study was to identify macrophage phenotypes (host defense or resolution and repair) present within the bovine ileum of naturally infected cattle, as well as to ascertain abundance of each macrophage phenotype present during different stages of MAP infection. Immunofluorescent (IF) labeling was performed on frozen bovine mid-ileal tissue sections collected from 28 Holstein dairy cows. Comprehensive IF staining for cytokines, such as IFN-γ, IL-1Ra, IL-1β, IL-10, TGF-β, TNF-α, and uNOS, along with markers such as CD163, CD206, and TLR4, served to define the macrophage phenotypes. Overall, cows in the clinical stage of disease demonstrated significantly higher numbers of resolution and repair macrophages and lower numbers of host defense macrophages in the ileal tissue. Interestingly, subclinically affected cows with asymptomatic disease had a nearly equal ratio of host defense and resolution and repair macrophage phenotypes, whereas macrophage phenotype was skewed to a host defense macrophage in the tissues of the control noninfected cows. The preponderance of M2-like resolution and repair phenotype for macrophages in the tissues of cows with clinical disease would explain why the host fails to control and/or clear the infection, leading to a higher MAP burden. The results of the current study offer insight into the disparate macrophage phenotypes present in the bovine ileum during different stages of infection.

Johne's disease is a chronic infection of the small intestine caused by Mycobacterium avium subspecies paratuberculosis (MAP), an intracellular bacterium. The events of pathogen survival within the host cell(s), chronic inflammation and the progression from asymptomatic subclinical stage to an advanced clinical stage of infection, are poorly understood. This study examines gene expression in the ileocecal valve (ICV) of Holstein dairy cows at different stages of MAP infection. The ICV is known to be a primary site of MAP colonization and provides an ideal location to identify genes that are relevant to the progression of this disease. RNA was prepared from ICV tissues and RNA-Seq was used to compare gene transcription between clinical, subclinical, and uninfected control animals. Interpretation of the gene expression data was performed using pathway analysis and gene ontology categories containing multiple differentially expressed genes. Results demonstrated that many of the pathways that had strong differential gene expression between uninfected control and clinical cows were related to the immune system, such as the T- and B-cell receptor signaling, apoptosis, NOD-like receptor signaling, and leukocyte transendothelial migration pathways. In contrast, the comparison of gene transcription between control and subclinical cows identified pathways that were primarily involved in metabolism. The results from the comparison between clinical and subclinical animals indicate recruitment of neutrophils, up regulation of lysosomal peptidases, increase in immune cell transendothelial migration, and modifications of the extracelluar matrix. This study provides important insight into how cattle respond to a natural MAP infection at the gene transcription level within a key target tissue for infection.

Mycobacterium avium subsp. paratuberculosis (MAP) purified protein derivatives (PPDs) are immunologic reagents prepared from cultured filtrates of the type strain. Traditional production consists of floating culture incubation at 37°C, organism inactivation by autoclaving, coarse filtration, and protein precipitation. Three traditional production PPDs were used in this study including lot 9801, which served as a reference and has been used in the field for decades. Alternative production PPDs (0902A and 0902B), in which the autoclaving step was removed, were also analyzed in this study. SDS-PAGE analysis revealed protein smearing in traditional PPDs, but distinct bands were observed in the alternative PPD preparations. Antibody bound distinct protein bands in the alternative PPDs by immunoblot analysis, whereas an immunoreactive smear was observed with the traditional PPDs. Mass spectrometry identified 194 proteins among three PPD lots representing the two different production methods, ten of which were present in all PPDs examined. Selected proteins identified by mass spectrometry were recombinantly expressed and purified from E. coli and evaluated by the guinea pig potency test. Seven recombinant proteins showed greater erythema as compared to the reference PPD lot 9801 in paired guinea pigs and were able to stimulate interferon-gamma production in blood from Johne's positive animals. These results suggest that autoclaving culture suspensions is not a necessary step in PPD production and specific proteins could supplant the PPD antigen for intradermal skin testing procedures and for use as in-vitro assay reagents.

It has been shown that Mycobacterium avium subspecies paratuberculosis (M. paratuberculosis) activates the Mitogen Activated Protein Kinase (MAPK) p38 pathway, yet it is unclear which components of M. paratuberculosis are involved in the process. Therefore, a set of 42 M. paratuberculosis recombinant proteins expressed from coding sequences annotated as lipoproteins were screened for their ability to induce IL-10 expression, an indicator of MAPKp38 activation, in bovine monocyte-derived macrophages. A recombinant lipoprotein, designated as MAP3837c, was among a group of 6 proteins that strongly induced IL-10 gene transcription in bovine macrophages, averaging a 3.1-fold increase compared to non-stimulated macrophages. However, a parallel increase in expression of IL-12 and TNF-α was only observed in macrophages exposed to a subset of these 6 proteins. Selected recombinant proteins were further analyzed for their ability to enhance survival of M. avium within bovine macrophages as measured by recovered viable bacteria and nitrite production. All 6 IL-10 inducing MAP recombinant proteins along with M. paratuberculosis cells significantly enhanced phosphorylation of MAPK-p38 in bovine macrophages. Although these proteins are likely not post translationally lipidated in E. coli and thus is a limitation in this study, these results form the foundation of how the protein component of the lipoprotein interacts with the immune system. Collectively, these data reveal M. paratuberculosis proteins that might play a role in MAPK-p38 pathway activation and hence in survival of this organism within bovine macrophages.

Mycobacterium avium subsp. paratuberculosis (MAP) is an intracellular bacterial pathogen that causes Johne's disease (JD) in cattle and other animals. The hallmark of MAP infection in the early stages is a strong protective cell-mediated immune response (Th1-type), characterized by antigen-specific γ-interferon (IFN-γ). The Th1 response wanes with disease progression and is supplanted by a non-protective humoral immune response (Th2-type). Interleukin-10 (IL-10) is believed to play a critical role in the regulation of host immune responses to MAP infection and potentially orchestrate the reversal of Th1/Th2 immune dominance during disease progression. However, how its role correlates with MAP infection remains to be completely deciphered. We developed mathematical models to explain probable mechanisms for IL-10 involvement in MAP infection. We tested our models with IL-4, IL-10, IFN-γ, and MAP fecal shedding data collected from calves that were experimentally infected and followed over a period of 360 days in the study of Stabel and Robbe-Austerman (2011). Our models predicted that IL-10 can have different roles during MAP infection, (i) it can suppress the Th1 expression, (ii) can enhance Th2 (IL-4) expression, and (iii) can suppress the Th1 expression in synergy with IL-4. In these predicted roles, suppression of Th1 responses was correlated with increased number of MAP. We also predicted that Th1-mediated responses (IFN-γ) can lead to high expression of IL-10 and that infection burden regulates Th2 suppression by the Th1 response. Our models highlight areas where more experimental data is required to refine our model assumptions, and further test and investigate the role of IL-10 in MAP infection.

BackgroundBovine tuberculosis is a highly prevalent infectious disease of cattle worldwide; however, infection in the United States is limited to 0.01% of dairy herds. Thus detection of bovine TB is confounded by high background infection with M. avium subsp. paratuberculosis. The present study addresses variations in the circulating peptidome based on the pathogenesis of two biologically similar mycobacterial diseases of cattle.Methodology/principal findingsWe hypothesized that serum proteomes of animals in response to either M. bovis or M. paratuberculosis infection will display several commonalities and differences. Sera prospectively collected from animals experimentally infected with either M. bovis or M. paratuberculosis were analyzed using high-resolution proteomics approaches. iTRAQ, a liquid chromatography and tandem mass spectrometry approach, was used to simultaneously identify and quantify peptides from multiple infections and contemporaneous uninfected control groups. Four comparisons were performed: 1) M. bovis infection versus uninfected controls, 2) M. bovis versus M. paratuberculosis infection, 3) early, and 4) advanced M. paratuberculosis infection versus uninfected controls. One hundred and ten differentially elevated proteins (P < or = 0.05) were identified. Vitamin D binding protein precursor (DBP), alpha-1 acid glycoprotein, alpha-1B glycoprotein, fetuin, and serine proteinase inhibitor were identified in both infections. Transthyretin, retinol binding proteins, and cathelicidin were identified exclusively in M. paratuberculosis infection, while the serum levels of alpha-1-microglobulin/bikunin precursor (AMBP) protein, alpha-1 acid glycoprotein, fetuin, and alpha-1B glycoprotein were elevated exclusively in M. bovis infected animals.Conclusions/significanceThe discovery of these biomarkers has significant impact on the elucidation of pathogenesis of two mycobacterial diseases at the cellular and the molecular level and can be applied in the development of mycobacterium-specific diagnostic tools for the monitoring progression of disease, response to therapy, and/or vaccine based interventions.