Search

Item does not contain fulltext, BACKGROUND: Anti-drug antibodies are associated with treatment failure to anti-TNF agents in patients with inflammatory bowel disease (IBD). AIM: To assess whether immunogenicity to a patient's first anti-TNF agent would be associated with immunogenicity to the second, irrespective of drug sequence METHODS: We conducted a UK-wide, multicentre, retrospective cohort study to report rates of immunogenicity and treatment failure of second anti-TNF therapies in 1058 patients with IBD who underwent therapeutic drug monitoring for both infliximab and adalimumab. The primary outcome was immunogenicity to the second anti-TNF agent, defined at any timepoint as an anti-TNF antibody concentration ≥9 AU/ml for infliximab and ≥6 AU/ml for adalimumab. RESULTS: In patients treated with infliximab and then adalimumab, those who developed antibodies to infliximab were more likely to develop antibodies to adalimumab, than patients who did not develop antibodies to infliximab (OR 1.99, 95%CI 1.27-3.20, p = 0.002). Similarly, in patients treated with adalimumab and then infliximab, immunogenicity to adalimumab was associated with subsequent immunogenicity to infliximab (OR 2.63, 95%CI 1.46-4.80, p < 0.001). For each 10-fold increase in anti-infliximab and anti-adalimumab antibody concentration, the odds of subsequently developing antibodies to adalimumab and infliximab increased by 1.73 (95% CI 1.38-2.17, p < 0.001) and 1.99 (95%CI 1.34-2.99, p < 0.001), respectively. Patients who developed immunogenicity with undetectable drug levels to infliximab were more likely to develop immunogenicity with undetectable drug levels to adalimumab (OR 2.37, 95% CI 1.39-4.19, p < 0.001). Commencing an immunomodulator at the time of switching to the second anti-TNF was associated with improved drug persistence in patients with immunogenic, but not pharmacodynamic failure. CONCLUSION: Irrespective of drug sequence, immunogenicity to the first anti-TNF agent was associated with immunogenicity to the seco

Item does not contain fulltext, Anti tumour necrosis factor (anti-TNF) drugs increase the risk of serious respiratory infection and impair protective immunity following pneumococcal and influenza vaccination. Here we report SARS-CoV-2 vaccine-induced immune responses and breakthrough infections in patients with inflammatory bowel disease, who are treated either with the anti-TNF antibody, infliximab, or with vedolizumab targeting a gut-specific anti-integrin that does not impair systemic immunity. Geometric mean [SD] anti-S RBD antibody concentrations are lower and half-lives shorter in patients treated with infliximab than vedolizumab, following two doses of BNT162b2 (566.7 U/mL [6.2] vs 4555.3 U/mL [5.4], p <0.0001; 26.8 days [95% CI 26.2 - 27.5] vs 47.6 days [45.5 - 49.8], p <0.0001); similar results are also observed with ChAdOx1 nCoV-19 vaccination (184.7 U/mL [5.0] vs 784.0 U/mL [3.5], p <0.0001; 35.9 days [34.9 - 36.8] vs 58.0 days [55.0 - 61.3], p value < 0.0001). One fifth of patients fail to mount a T cell response in both treatment groups. Breakthrough SARS-CoV-2 infections are more frequent (5.8% (201/3441) vs 3.9% (66/1682), p = 0.0039) in patients treated with infliximab than vedolizumab, and the risk of breakthrough SARS-CoV-2 infection is predicted by peak anti-S RBD antibody concentration after two vaccine doses. Irrespective of the treatments, higher, more sustained antibody levels are observed in patients with a history of SARS-CoV-2 infection prior to vaccination. Our results thus suggest that adapted vaccination schedules may be required to induce immunity in at-risk, anti-TNF-treated patients.

Item does not contain fulltext, BACKGROUND AND AIMS: Infliximab attenuates serological responses to SARS-CoV-2 infection. Whether this is a class effect, or if anti-tumour necrosis factor [anti-TNF] level influences serological responses, remains unknown. METHODS: Seroprevalence and the magnitude of SARS-CoV-2 nucleocapsid antibody responses were measured in surplus serum from 11 422 (53.3% [6084] male; median age 36.8 years) patients with immune-mediated inflammatory diseases, stored at six therapeutic drug monitoring laboratories between January 29 and September 30, 2020. Data were linked to nationally held SARS-CoV-2 PCR results to July 11, 2021. RESULTS: Rates of PCR-confirmed SARS-CoV-2 infection were similar across treatment groups. Seroprevalence rates were lower in infliximab- and adalimumab- than vedolizumab-treated patients (infliximab: 3.0% [178/5893], adalimumab: 3.0% [152/5074], vedolizumab: 6.7% [25/375], p = 0.003). The magnitude of SARS-CoV-2 reactivity was similar in infliximab- vs adalimumab-treated patients (median 4.30 cut-off index [COI] [1.94-9.96] vs 5.02 [2.18-18.70], p = 0.164), but higher in vedolizumab-treated patients (median 21.60 COI [4.39-68.10, p < 0.004). Compared to patients with detectable infliximab and adalimumab drug levels, patients with undetectable drug levels [<0.8 mg/L] were more likely to be seropositive for SARS-CoV-2 antibodies. One-third of patients who had PCR testing prior to antibody testing failed to seroconvert, all were treated with anti-TNF. Subsequent positive PCR-confirmed SARS-CoV-2 was seen in 7.9% [12/152] of patients after a median time of 183.5 days [129.8-235.3], without differences between drugs. CONCLUSION: Anti-TNF treatment is associated with lower SARS-CoV-2 nucleocapsid seroprevalence and antibody reactivity when compared to vedolizumab-treated patients. Higher seropositivity rates in patients with undetectable anti-TNF levels support a causal relationship, although confounding factors, such as combination therapy with a immunomod

Anti tumour necrosis factor (anti-TNF) drugs increase the risk of serious respiratory infection and impair protective immunity following pneumococcal and influenza vaccination. Here we report SARS-CoV-2 vaccine-induced immune responses and breakthrough infections in patients with inflammatory bowel disease, who are treated either with the anti-TNF antibody, infliximab, or with vedolizumab targeting a gut-specific anti-integrin that does not impair systemic immunity. Geometric mean [SD] anti-S RBD antibody concentrations are lower and half-lives shorter in patients treated with infliximab than vedolizumab, following two doses of BNT162b2 (566.7 U/mL [6.2] vs 4555.3 U/mL [5.4], p <0.0001; 26.8 days [95% CI 26.2 - 27.5] vs 47.6 days [45.5 - 49.8], p <0.0001); similar results are also observed with ChAdOx1 nCoV-19 vaccination (184.7 U/mL [5.0] vs 784.0 U/mL [3.5], p <0.0001; 35.9 days [34.9 - 36.8] vs 58.0 days [55.0 - 61.3], p value < 0.0001). One fifth of patients fail to mount a T cell response in both treatment groups. Breakthrough SARS-CoV-2 infections are more frequent (5.8% (201/3441) vs 3.9% (66/1682), p = 0.0039) in patients treated with infliximab than vedolizumab, and the risk of breakthrough SARS-CoV-2 infection is predicted by peak anti-S RBD antibody concentration after two vaccine doses. Irrespective of the treatments, higher, more sustained antibody levels are observed in patients with a history of SARS-CoV-2 infection prior to vaccination. Our results thus suggest that adapted vaccination schedules may be required to induce immunity in at-risk, anti-TNF-treated patients.

Background: Remote Australian Aboriginal communities have among the highest diagnosed rates of sexually transmissible infections (STIs) in the world. We did a trial to assess whether continuous improvement strategies related to sexual health could reduce infection rates. Methods: In this stepped-wedge, cluster-randomised trial (STIs in remote communities: improved and enhanced primary health care [STRIVE]), we recruited primary health-care centres serving Aboriginal communities in remote areas of Australia. Communities were eligible to participate if they were classified as very remote, had a population predominantly of Aboriginal people, and only had one primary health-care centre serving the population. The health-care centres were grouped into clusters on the basis of geographical proximity to each other, population size, and Aboriginal cultural ties including language connections. Clusters were randomly assigned into three blocks (year 1, year 2, and year 3 clusters) using a computer-generated randomisation algorithm, with minimisation to balance geographical region, population size, and baseline STI testing level. Each year for 3 years, one block of clusters was transitioned into the intervention phase, while those not transitioned continued usual care (control clusters). The intervention phase comprised cycles of reviewing clinical data and modifying systems to support improved STI clinical practice. All investigators and participants were unmasked to the intervention. Primary endpoints were community prevalence and testing coverage in residents aged 16–34 years for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. We used Poisson regression analyses on the final dataset and compared STI prevalences and testing coverage between control and intervention clusters. All analyses were by intention to treat and models were adjusted for time as an independent covariate in overall analyses. This study was registered with the Australia and New Ze

Singapore s population-dense, urban environment presents a unique context for her increasingly important aquaculture industry. This paper provides an overview of Singapore s existing aquatic emergency preparedness and response systems, which have been constructed and refined by the Agri-Food and Veterinary Authority (AVA) in view of past experience with detections of pathogens of warmwater fish. These systems have been developed to fulfil Singapore s obligations as an OIE member country and AVA s duty to safeguard food security, animal and public health. As a trade and export hub, it is critical for Singapore to have timely detection and reporting of diseases which can have an impact on trade. Singapore also needs to balance the needs and perceptions of the multiple stakeholders using the limited space and resources in our island state. Finally, this paper outlines the current issues and gaps of Singapore s existing aquatic emergency preparedness and response systems.

Introduction: Immunotherapy is an increasingly important component of care in the management of several advanced malignancies, including metastatic melanoma and non-small cell lung cancer. Immune-mediated adverse events to therapy involving the gastrointestinal tract have been described, namely, autoimmune colitis and hepatitis. We aimed to evaluate the incidence, risk factors, and management of the gastrointestinal-related autoimmune side effects of checkpoint inhibitor therapy. Method(s): We conducted a retrospective audit of the files of all patients who received checkpoint inhibitor therapy at a major tertiary referral center from January 1, 2015, to June 1, 2017. We focused on the cytotoxic T-lym-phocyte-associated antigen 4 (CTLA-4) inhibitor ipilimumab and the programmed cell death 1 (PD-1) inhibitors nivolumab and pembrolizumab. We analyzed the data in two groups: patients who developed any autoimmune complications while being treated with checkpoint inhibitor therapy and patients who did not. We assessed for differences in pre-existing autoimmune comorbidities and liver function test results over a 16-week period from commencement of their therapy. We then performed an in-depth review of the management of the patients who developed autoimmune colitis and hepatitis. Result(s): We identified 56 patients receiving checkpoint inhibitor ther-apy, of whom 45 patients (80.4%) received nivolumab, seven (12.5%) received ipilimumab, and one (1.8%) received pembrolizumab. Three patients received both nivolumab and ipilimumab (5.4%). A total of 14/56 patients (33%) developed an autoimmune-related side effect. Of these 14 patients, four (28.6%) developed autoimmune colitis and one (7.1%) developed autoimmune hepatitis. The other common autoim-mune complications were hyperthyroidism (2, 14.3%), pneumonitis (2, 14.3%), and hypophysitis (2, 14.3%). There was no statistically significant difference between the two groups at baseline with respect to age, sex, or ethnicity. B

Introduction: Intragastric feeding via percutaneous gastrostomy (PEG) is unsuitable for many patients, and jejunal feeding is required. A PEG tube with a jejunostomy extension tube (PEG+J) is commonly used but is frequently complicated by retrograde migration of the jejunostomy extension tube into the stomach, requiring endoscopic replacement. The PEG-pedi-PEG procedure is a new method aimed at reducing this complication. In this procedure, a pediatric PEG tube acts as a jejunostomy extension and is inserted through an adult PEG tube. The pediatric bumper provides an anchor in the small bowel and remains in position by peristalsis. Method(s): We performed a single-center retrospective study looking at patients undergoing PEG-pedi-PEG insertion after a previous PEG+J insertion. The PEG+J insertion was taken as the initial time point for all calculations. The main outcome recorded was number of endoscopic replacements, as well as time between these replacements, before and after PEG-pedi-PEG insertions. If the PEG-pedi-PEG was not replaced after initial insertion, then the time until last follow-up was recorded. Additionally, we observed early and late complication rates after PEG-pedi-PEG insertions. Result(s): Six patients were identified who had undergone both procedures. Indications for jejunal feeding included gastroparesis (three patients), duodenal stricture (one), narcotic bowel syndrome (one), and Parkinson's disease (one). Mean time from PEG+J to PEG-pedi-PEG insertion was 19 months (range, 2-41 months). Mean time of follow-up after PEG-pedi-PEG insertion was 10 months (range, 7-13 months). The number of endoscopic replacements per patient after PEG+J insertion, before PEG-pedi-PEG insertion, ranged from zero to 11. The most common indication was migration of the jejunostomy extension tube into the stomach, followed by an occluded jejunostomy extension. The number of endo-scopic replacements per patient after PEG-pedi-PEG insertion ranged from zero to one. T

Introduction: Upper gastrointestinal bleeding (UGIB) is the most common gastrointestinal emergency and is associated with substantial morbidity and mortality. Studies have shown a prevalence of up to 150 patients per 100 000 population, with a mortality of 3-10% despite current standards of care. Presentation of UGIB varies from frank hematemesis to coffee ground vomitus (CGV), and melena. CGV, defined as the passage of black material which is assumed to be blood, has traditionally been considered to represent lower-risk bleeding when compared with frank hematemesis or melena. Aim(s): We aimed to compare outcomes and their severity for patients presenting with non-variceal UGIB based on their presenting symptoms (hematemesis, CGV, and/or melena) in an Australian patient cohort. Method(s): Patients presenting with UGIB to three Australian centers (two tertiary hospitals and one regional hospital) were prospectively included over a 22-month period from 2016 to 2017. Data were collected by specialist registrars using a purpose-built smartphone app. Background demographics and presenting symptom of UGIB were recorded. Patients with UGIB secondary to variceal bleeding were excluded. Primary outcome was in-hospital mortality. Secondary outcomes were: a composite end-point of inpatient mortality, rebleeding, and endoscopic, radiological, or surgical intervention; blood transfusion requirement; intensive care unit (ICU) admission; rebleeding; and hospital length of stay (LOS). Result(s): A total of 703 patients were included in the study. Median age was 67 years (IQR, 51-79) and 63% were male. Overall in-hospital mortality was 3.7%, and 60 patients (8.5%) experienced rebleeding. Median LOS was 4 days (IQR, 3-7 days), and 417 patients (59%) required blood transfusion, with a median transfusion requirement of 2 units (IQR, 2-4 units). Sixty-seven patients (10%) required repeat endoscopy, eight (1.1%) proceeded to surgery, and 23 (3.3%) required radiological embolization. The

Background: Young people living in remote Australian Aboriginal communities experience high rates of sexually transmissible infections (STIs). STRIVE (STIs in Remote communities, ImproVed and Enhanced primary care) was a cluster randomised control trial of a sexual health continuous quality improvement (CQI) program. As part of the trial, qualitative research was conducted to explore staff perceptions of the CQI components, their normalisation and integration into routine practice, and the factors which influenced these processes. Methods: In-depth semi-structured interviews were conducted with 41 clinical staff at 22 remote community clinics during 2011-2013. Normalisation process theory was used to frame the analysis of interview data and to provide insights into enablers and barriers to the integration and normalisation of the CQI program and its six specific components. Results: Of the CQI components, participants reported that the clinical data reports had the highest degree of integration and normalisation. Action plan setting, the Systems Assessment Tool, and the STRIVE coordinator role, were perceived as adding value to the program, but were less readily integrated or normalised. The remaining two components (dedicated funding for health promotion and service incentive payments) were seen as least relevant. Our analysis also highlighted factors which enabled greater integration of the CQI components. These included familiarity with CQI tools, increased accountability of health centre staff and the translation of the CQI program into guideline-driven care. The analysis also identified barriers, including high staff turnover, limited time involved in the program and competing clinical demands and programs. Conclusions: Across all of the CQI components, the clinical data reports had the highest degree of integration and normalisation. The action plans, systems assessment tool and the STRIVE coordinator role all complemented the data reports and allowed these co

Purpose: The aim of this study was to investigate the driving performance of drivers with autism spectrum disorders under complex driving conditions. Method: Seventeen drivers with autism spectrum disorders and 18 typically developed drivers participated in a driving simulator trial. Prior to the assessment, participants completed the Driving Behaviour Questionnaire and measurements of cognitive and visual-motor ability. The driving simulation involved driving in an urban area with dense traffic and unpredictable events. Results: In comparison with the typically developed group, drivers with autism spectrum disorders reported significantly more lapses in driving, committed more mistakes on the driving simulator, and were slower to react in challenging situations, such as driving through intersections with abrupt changes in traffic lights. However, they were also less likely to tailgate other vehicles, as measured by time-to-collision between vehicles, on the driving simulator. Conclusions: The performances of licensed drivers with autism spectrum disorders appeared to be safer in respect to car-following distance but were poorer in their response to challenging traffic situations. Driver education for individuals with autism spectrum disorders should focus on quick identification of hazards, prompt execution of responses, and effective allocation of attention to reduce lapses in driving.Implications for rehabilitationDrivers with autism spectrum disorders reported significantly more lapses during driving.Drivers with autism spectrum disorders were observed to be poorer in traffic scenarios requiring critical response.Driver education for individuals with autism spectrum disorders should focus on managing anxiety and effective attention allocation while driving.Driving simulators can be used as a safe means for training critical response to challenging traffic scenarios.

© 2017, Springer Science+Business Media New York. The symptomatology of autism spectrum disorder (ASD) can make driving risky, but little is known about the on-road driving behaviour of individuals with ASD. This study assessed and compared the on-road driving performance of drivers with and without ASD, and explored how the symptomatology of ASD hinders or facilitates on-road driving performance. Sixteen drivers with ASD and 21 typically-developed drivers participated in the study. Drivers with ASD underperformed in vehicle manoeuvring, especially at left-turns, right-turns and pedestrian crossings. However, drivers with ASD outperformed the TD group in aspects related to rule-following such as using the indicator at roundabouts and checking for cross-traffic when approaching intersections. Drivers with ASD in the current study presented with a range of capabilities and weaknesses during driving.

© 2017 Hanley & Belfus. Study Design: Systematic review. Introduction: Median nerve mobilization is one of the interventions used in the treatment of carpal tunnel syndrome (CTS). However, it is uncertain how many types of mobilization techniques are described in the current literature or the relative effectiveness of these techniques in treating CTS. Purpose of the Study: The aim of this review was to describe the types and effectiveness of median nerve mobilization techniques studied in the CTS literature. Methods: Electronic searches of 5 databases and manual searches of references lists located randomized controlled trials studies published between 2000 and April 2015. Quality appraisal for each study was conducted using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields by 2 independent reviewers. Results: Nine randomized controlled trial studies describing various median nerve mobilization techniques used in the treatment of CTS were included. All studies were rated as of "adequate", "good", or "strong" quality for the Standard Quality Assessment Criteria. Three techniques of median nerve mobilization were described. Treatment outcomes included measures of electrodiagnostic testing, functional performance, pain, physical examination, sensation, and strength. Standardized mean differences for the treatment outcomes ranged from very small to large (0.05-1.71). Conclusion: The findings are inconclusive regarding the effectiveness of each mobilization technique due to methodological limitations in the current body of research. Therefore, there is a clear need for high-quality controlled studies to examine various approaches to median nerve mobilization techniques in the treatment of CTS. Level of evidence: 2a.

Background: In high-incidence Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) settings, annual re-testing is an important public health strategy. Using baseline laboratory data (2009–10) from a cluster randomised trial in 67 remote Aboriginal communities, the extent of re-testing was determined, along with the associated patient, staffing and health centre factors. Methods: Annual testing was defined as re-testing in 9–15 months (guideline recommendation) and a broader time period of 5–15 months following an initial negative CT/NG test. Random effects logistic regression was used to determine factors associated with re-testing. Results: Of 10 559 individuals aged ≥16 years with an initial negative CT/NG test (median age = 25 years), 20.3% had a re-test in 9–15 months (23.6% females vs 15.4% males, P < 0.001) and 35.2% in 5–15 months (40.9% females vs 26.5% males, P < 0.001). Factors independently associated with re-testing in 9–15 months in both males and females were: younger age (16–19, 20–24 years); and attending a centre that sees predominantly (>90%) Aboriginal people. Additional factors independently associated with re-testing for females were: being aged 25–29 years, attending a centre that used electronic medical records, and for males, attending a health centre that employed Aboriginal health workers and more male staff. Conclusions: Approximately 20% of people were re-tested within 9–15 months. Re-testing was more common in younger individuals. Findings highlight the importance of recall systems, Aboriginal health workers and male staff to facilitate annual re-testing. Further initiatives may be needed to increase re-testing.

The Central Australian Aboriginal Congress is a large Aboriginal community-controlled health service based in Alice Springs in the Northern Territory. Since the 1970s, Congress has developed a comprehensive model of primary health care delivering evidence-based services on a foundation of cultural appropriateness. In recent years, the community-elected Congress Board has focused on improving the developmental outcomes of Aboriginal children. This has led to the development of an innovative model for the delivery of child and family services, based on the belief that the best way to “close the gap” is to make sure it is not created in the first place.

Background: Despite two decades of interventions, rates of sexually transmissible infections (STI) in remote Australian Aboriginal communities remain unacceptably high. Routine notifications data from 2011 indicate rates of chlamydia and gonorrhoea among Aboriginal people in remote settings were 8 and 61 times higher respectively than in the non-Indigenous population.Methods/design: STRIVE is a stepped-wedge cluster randomised trial designed to compare a sexual health quality improvement program (SHQIP) to usual STI clinical care delivered in remote primary health care services. The SHQIP is a multifaceted intervention comprising annual assessments of sexual health service delivery, implementation of a sexual health action plan, six-monthly clinical service activity data reports, regular feedback meetings with a regional coordinator, training and financial incentive payments. The trial clusters comprise either a single community or several communities grouped together based on geographic proximity and cultural ties. The primary outcomes are: prevalence of chlamydia, gonorrhoea and trichomonas in Aboriginal residents aged 16-34 years, and performance in clinical management of STIs based on best practice indicators. STRIVE will be conducted over five years comprising one and a half years of trial initiation and community consultation, three years of trial conditions, and a half year of data analysis. The trial was initiated in 68 remote Aboriginal health services in the Northern Territory, Queensland and Western Australia.Discussion: STRIVE is the first cluster randomised trial in STI care in remote Aboriginal health services. The trial will provide evidence to inform future culturally appropriate STI clinical care and control strategies in communities with high STI rates.Trial registration: Australian and New Zealand Clinical Trials Registry ACTRN12610000358044. © 2013 Ward et al.; licensee BioMed Central Ltd.

Background: Signs and symptoms of Parkinson’s Disease (PD) include a combination of slowness of movement, increased tone, tremor and loss of postural reflexes. Cognitive changes and dementia can also be found in older people affected by PD. The excessive expenditure of cerebral resources in multitasks can cause cognitive overload resulting in deterioration of functional performance. Previous research has highlighted that the balance of cognitive load is essential for safe driving; however, this has not yet been researched in relation to people with PD. Coupled with mental inflexibility and sluggish reasoning, PD drivers exposed to demanding traffic scenarios may reach dangerous levels of cognitive overload. The present study employed computation of arithmetic sums as secondary task to investigate the effect of cognitive overloading on older PD drivers. Methodology: A pre-post case-control study design was implemented. Convenience sample of 28 mild to moderate stages of PD drivers and 30 age-matched healthy controls were recruited and their motor and cognitive functions were assessed using the Digit Vigilance Test (DVT), Perdue Pegboard, Symbol Digit Modalities Test (SDMT) and Trail-Making Test- Part A and B. Participants were then assessed twice using a driving simulator: with and without exposure to the secondary task. Results: When compared with healthy controls, PD drivers scored lower in motor and cognitive psychometric assessments and performed less competently in driving assessments. However, PD drivers drove more cautiously and took more time to complete all the driving tests when compared with the healthy counterparts. With the distraction of the secondary task, both the performance of PD drivers and controls declined, but PD drivers to a greater extent. The Trail-Making Test-B was found to be valuable in predicting the overall performance of PD drivers. The ability of PD participants was observed to have significant deterioration in driving through T-juncti

Background: Despite two decades of interventions, rates of sexually transmissible infections (STI) in remote Australian Aboriginal communities remain unacceptably high. Routine notifications data from 2011 indicate rates of chlamydia and gonorrhoea among Aboriginal people in remote settings were 8 and 61 times higher respectively than in the non-Indigenous population.Methods/design: STRIVE is a stepped-wedge cluster randomised trial designed to compare a sexual health quality improvement program (SHQIP) to usual STI clinical care delivered in remote primary health care services. The SHQIP is a multifaceted intervention comprising annual assessments of sexual health service delivery, implementation of a sexual health action plan, six-monthly clinical service activity data reports, regular feedback meetings with a regional coordinator, training and financial incentive payments. The trial clusters comprise either a single community or several communities grouped together based on geographic proximity and cultural ties. The primary outcomes are: prevalence of chlamydia, gonorrhoea and trichomonas in Aboriginal residents aged 16-34 years, and performance in clinical management of STIs based on best practice indicators. STRIVE will be conducted over five years comprising one and a half years of trial initiation and community consultation, three years of trial conditions, and a half year of data analysis. The trial was initiated in 68 remote Aboriginal health services in the Northern Territory, Queensland and Western Australia.Discussion: STRIVE is the first cluster randomised trial in STI care in remote Aboriginal health services. The trial will provide evidence to inform future culturally appropriate STI clinical care and control strategies in communities with high STI rates.Trial registration: Australian and New Zealand Clinical Trials Registry ACTRN12610000358044. © 2013 Ward et al.; licensee BioMed Central Ltd.

This is the first pathological description of ‘scale drop syndrome’ (SDS) in Asian seabass, Lates calcarifer Bloch. Cumulative mortality was estimated at 40–50%. The vasculitis in all major organs including the skin and associated tissue necrosis was distinctive. The dermis overlying scale beds was often necrotic and associated with scale loss. Necrosis of splenic ellipsoids, renal glomeruli and choroid rete glands of eye were further hallmarks of a disease with systemic vascular involvement. The brain was not spared vascular damage, and the resulting multifocal encephalomalacia probably accounts for the spiral swimming behaviour in some affected fish. Other lesions included accentuated hepatic lobulation and gastric gland necrosis. Nuclear chromatin margination and karyolysis in hepatocytes, renal tubular epithelium and gastric and intestinal epithelium suggest specific targeting of cells. Basophilic cytoplasmic inclusions were present in spleen, kidney, liver, heart and choroid rete, but they were not prominent. Using transmission electron microscopy, two morphological forms of virions were observed: single- and double-enveloped hexagonal virions. Based on size and morphology, these virions resemble iridovirus or herpesvirus. The cause of SDS is unknown, but the pathological changes, especially the vasculitis, suggest an infectious aetiology, possibly viral.

Background: Current methods of determining licence retainment or cancellation is through on-road driving tests. Previous research has shown that occupational therapists frequently assess drivers’ visual attention while sitting in the back seat on the opposite side of the driver. Since the eyes of the driver are not always visible, assessment by eye contact becomes problematic. Such procedural drawbacks may challenge validity and reliability of the visual attention assessments. In terms of correctly classified attention, the aim of the study was to establish the accuracy and the inter-rater reliability of driving assessments of visual attention from the back seat. Furthermore, by establishing eye contact between the assessor and the driver through an additional mirror on the wind screen, the present study aimed to establish how much such an intervention would enhance the accuracy of the visual attention assessment. Methods: Two drivers with Parkinson’s disease (PD) and six control drivers drove a fixed route in a driving simulator while wearing a head mounted eye tracker. The eye tracker data showed where the foveal visual attention actually was directed. These data were time stamped and compared with the simultaneous manual scoring of the visual attention of the drivers. In four of the drivers, one with Parkinson’s disease, a mirror on the wind screen was set up to arrange for eye contact between the driver and the assessor. Inter-rater reliability was performed with one of the Parkinson drivers driving, but without the mirror. Results: Without mirror, the overall accuracy was 56% when assessing the three control drivers and with mirror 83%. However, for the PD driver without mirror the accuracy was 94%, whereas for the PD driver with a mirror the accuracy was 90%. With respect to the inter-rater reliability, a 73% agreement was found.Conclusion: If the final outcome of a driving assessment is dependent on the subcategory of a protocol assessing visual attention, we