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Background\ud \ud Studies have identified young adults as more likely to use emergency departments for ‘clinically unnecessary’ problems, with limited similar evidence for emergency ambulance use. Media portrayals depict young adults as motivated by ‘convenience’, but little research has explored the reasons for their help-seeking behaviour.\ud \ud \ud \ud Methods\ud \ud Qualitative interviews with 16 young adults (18-30) considered by clinicians to have made unnecessary use of emergency ambulance, emergency department or an urgent GP appointment. Data analysis was informed by interpretive phenomenological analysis.\ud \ud \ud \ud Findings\ud \ud A number of interrelated factors contributed to participants’ decisions. They were anxious about the seriousness of their symptoms, sometimes exacerbated by reduced coping capacity due to poor mental health or life stresses. They looked to others to facilitate their decision making, who sometimes encouraged urgent contact. They wanted to avoid impact on existing day-to-day commitments including work or study. They had strong views about different health services, sometimes based on frustration with lack of resolution of on-going health problems. Convenience was not identified as a significant factor, although some actions could be interpreted in this light if the context was not considered.\ud \ud \ud \ud Conclusions\ud \ud Young adults make ‘clinically unnecessary’ use of urgent and emergency care for more than convenience. Their decisions need to be understood in relation to the complexity of their experience, including lack of confidence in making health-related decisions, lowered coping capacity and concern to maintain normal daily life.

Cirrhosis-associated immune dysfunction (CAID) contributes to disease progression and organ failure development. We interrogated immune system function in nonseptic compensated and decompensated cirrhotic patients using the TruCulture whole blood stimulation system, a novel technique that allows a more accurate representation than traditional methods, such as peripheral blood mononuclear cell culture, of the immune response in vivo. Thirty cirrhotics (21 decompensated and 9 compensated) and seven healthy controls (HCs) were recruited. Whole blood was drawn directly into three TruCulture tubes [unstimulated to preloaded with heat-killed Escherichia coli 0111:B4 (HKEB) or lipopolysaccharide (LPS)] and incubated in dry heat blocks at 37°C for 24 h. Cytokine analysis of the supernatant was performed by multiplex assay. Cirrhotic patients exhibited a robust proinflammatory response to HKEB compared with HCs, with increased production of interferon-γ-induced protein 10 (IP-10) and IFN-λ1, and to LPS, with increased production of IFN-λ1. Decompensated patients demonstrated an augmented immune response compared with compensated patients, orchestrated by an increase in type I, II, and III interferons, and higher levels of IL-1β, IL-6, and IL-8 post-LPS stimulation. IL-1β, TNF-α, and IP-10 post-HKEB stimulation and IP-10 post-LPS stimulation negatively correlated with biochemical markers of liver disease severity and liver disease severity scores. Cirrhotic patients exposed to bacterial products exhibit an exaggerated inflammatory response orchestrated by IFNs, IL-6, and IL-8. Poststimulation levels of a number of proinflammatory cytokines negatively correlate with markers of liver disease severity raising the possibility that the switch to an immunodeficient phenotype in CAID may commence earlier in the course of advanced liver disease. NEW & NOTEWORTHY Decompensated cirrhotic patients, compared with compensated patients, exhibit a greater exaggerated inflammatory response to bacterial products orchestrated by interferons, IL-6, and IL-8. Postbacterial product stimulation levels of a number of pro-inflammatory cytokines negatively correlate with liver disease severity biomarkers and liver disease severity scores raising the possibility that the switch to an immunodeficient phenotype in cirrhosis-associated immune dysfunction may commence earlier in the course of advanced liver disease.

BackgroundAn emergency ambulance is not always the appropriate response for emergency medical service patients. Telephone advice aims to resolve low acuity calls over the phone, without sending an ambulance. In England, variation in rates of telephone advice and patient recontact between services raises concerns about inequities in care. To understand this variation, this study aimed to explore operational factors influencing the provision of telephone advice.MethodsThis is a multimethod qualitative study in three emergency medical services in England with different rates of telephone advice and recontact. Non-participant observation (120 hours) involved 20 call handlers and 27 clinicians (eg, paramedics). Interviews were conducted with call handlers, clinicians and clinician managers (n=20).ResultsServices varied in their views of the role of telephone advice, selection of their workforce, tasks clinicians were expected and permitted to do, and access to non-ambulance responses. Telephone advice was viewed either as an acceptable approach to managing demand or a way of managing risk. The workforce could be selected for their expertise or their inability to work ‘on-the-road’. Some services permitted proactive identification of calls for a lower priority response and provided access to a wider range of response options. The findings aligned with telephone advice rates for each service, particularly explaining why one service had lower rates.ConclusionSome of the variation observed can be explained by operational differences between services and some of it by access to alternative response options in the wider urgent and emergency care system. The findings indicate scope for greater consistency in the delivery of telephone advice to ensure the widest range of options to meet the needs of different populations, regardless of geographical location.

Summary Background The UK Government's implementation in 2008 of the Improving Access to Psychological Therapies (IAPT) initiative in England has hugely increased the availability of cognitive behavioural therapy (CBT) for the treatment of depression and anxiety in primary care. Counselling for depression—a form of person-centred experiential therapy (PCET)—has since been included as an IAPT-approved therapy, but there is no evidence of its efficacy from randomised controlled trials (RCTs), as required for recommendations by the National Institute for Health and Care Excellence. Therefore, we aimed to examine whether PCET is cost effective and non-inferior to CBT in the treatment of moderate and severe depression within the IAPT service. Methods This pragmatic, randomised, non-inferiority trial was done in the Sheffield IAPT service in England and recruited participants aged 18 years or older with moderate or severe depression on the Clinical Interview Schedule-Revised. We excluded participants presenting with an organic condition, a previous diagnosis of personality disorder, bipolar disorder, or schizophrenia, drug or alcohol dependency, an elevated clinical risk of suicide, or a long-term physical condition. Eligible participants were randomly assigned (1:1), independently of the research team, and stratified by site with permuted block sizes of two, four, or six, to receive either PCET or CBT by use of a remote, web-based system that revealed therapy after patient details were entered. Those assessing outcomes were masked to treatment allocation. Participants were seen by appropriately trained PCET counsellors and CBT therapists in accordance with the IAPT service delivery model. Depression severity and symptomatology measured by the Patient Health Questionnaire-9 (PHQ-9) at 6 months post-randomisation was the primary outcome, with the PHQ-9 score at 12 months post-randomisation being a key secondary outcome. These outcomes were analysed in the modified intention-to-treat population, which comprised all randomly assigned patients with complete data, and the per-protocol population, which comprised all participants who did not switch from their randomised treatment and received between four and 20 sessions. Safety was analysed in all randomly assigned patients. The non-inferiority margin was set a priori at 2 PHQ-9 points. Patient safety was monitored throughout the course of therapy, adhering to service risk procedures for monitoring serious adverse events. This trial is registered at the ISRCTN Registry, ISRCTN06461651, and is complete. Findings From Nov 11, 2014, to Aug 3, 2018, 9898 patients were referred to step three treatments in the Sheffield IAPT service for common mental health problems, of whom 761 (7·7%) were referred to the trial. Of these, we recruited and randomly assigned 510 participants to receive either PCET (n=254) or CBT (n=256). In the PCET group, 138 (54%) participants were female and 116 (46%) were male, and 225 (89%) were White, 16 (6%) were non-White, and 13 (5%) had missing ethnicity data. In the CBT group, 155 (61%) participants were female and 101 (39%) were male, and 226 (88%) were White, 17 (7%) were non-White, and 13 (5%) had missing ethnicity data. The 6-month modified intention-to-treat analysis comprised 401 (79%) of the enrolled participants (201 in the PCET group; 200 in the CBT group) and the 12-month modified intention-to-treat analysis comprised 319 participants (167 in the PCET group; 152 in the CBT group). The 6-month per-protocol analysis comprised 298 participants (154 in the PCET group; 144 in the CBT group). At 6 months post-randomisation, PCET was non-inferior to CBT in the intention-to-treat population (mean PHQ-9 score 12·74 [SD 6·54] in the PCET group and 13·25 [6·35] in the CBT group; adjusted mean difference −0·35 [95% CI −1·53 to 0·84]) and in the per-protocol population (12·73 [SD 6·57] in the PCET group and 12·71 [6·33] in the CBT group; 0·27 [95% CI −1·08 to 1·62]). At 12 months post-randomisation, there was a significant adjusted between-group difference in mean PHQ-9 score in favour of CBT (1·73 [95% CI 0·26–3·19]), with a 95% CI exceeding the 2-point non-inferiority margin. There were two deaths, one death by suicide in the PCET group and one due to chronic obstructive pulmonary disease in the CBT group. Both were assessed by the responsible clinician to be unrelated to the trial. In terms of using emergency departments for depression-related events, four people (three in the PCET group; one in the CBT group) made more than a single use and six people (three in the PCET group; three in the CBT group) made a single use. One patient in the PCET group had inpatient treatment for a depression-related event. Interpretation This trial is the first to examine the two most frequently administered psychological therapies in the IAPT service. The finding of non-inferiority of PCET to CBT at 6 months supports the results from large, routine, non-randomised datasets from the IAPT programme. Given the high demand for psychological therapies and the need for patient choice, our findings suggest the need for continued investment in the training and delivery of PCET for improving short-term outcomes, but suggest that PCET might be inferior to CBT at 12 months. Funding British Association for Counselling and Psychotherapy Research Foundation.

The role of gut microbiota in humans is of great interest, and metagenomics provided the possibilities for extensively analysing bacterial diversity in health and disease. Here we explored the human gut microbiome samples across 19 countries, performing compositional, functional and integrative analysis. To complement these data and analyse the stability of the microbiome, we followed 86 healthy Swedish individuals over one year, with four sampling times and extensive clinical phenotyping. The integrative analysis of temporal microbiome changes shows the existence of two types of species with a tendency to vary in abundance with time, here called outflow and inflow species. Importantly, the former tends to be enriched in disease, while the latter is enriched in health. We suggest that the decrease of disease-associated outflow and the increase of health-associated inflow species with time may be a fundamental albeit previously unrecognized aspect of the homeostasis maintenance in a healthy microbiome.

Background & Aims: Rifaximin-α is efficacious for the prevention of recurrent hepatic encephalopathy (HE), but its mechanism of action remains unclear. We postulated that rifaximin-α reduces gut microbiota-derived endotoxemia and systemic inflammation, a known driver of HE. Methods: In a placebo-controlled, double-blind, mechanistic study, 38 patients with cirrhosis and HE were randomised 1:1 to receive either rifaximin-α (550 mg BID) or placebo for 90 days. Primary outcome: 50% reduction in neutrophil oxidative burst (OB) at 30 days. Secondary outcomes: changes in psychometric hepatic encephalopathy score (PHES) and neurocognitive functioning, shotgun metagenomic sequencing of saliva and faeces, plasma and faecal metabolic profiling, whole blood bacterial DNA quantification, neutrophil toll-like receptor (TLR)-2/4/9 expression and plasma/faecal cytokine analysis. Results: Patients were well-matched: median MELD (11 rifaximin-α vs. 10 placebo). Rifaximin-α did not lead to a 50% reduction in spontaneous neutrophil OB at 30 days compared to baseline (p = 0.48). However, HE grade normalised (p = 0.014) and PHES improved (p = 0.009) after 30 days on rifaximin-α. Rifaximin-α reduced circulating neutrophil TLR-4 expression on day 30 (p = 0.021) and plasma tumour necrosis factor-α (TNF-α) (p

Changes in microbial metabolism have been used as the main approach to assess function and elucidate environmental and host-microbiome interactions. This can be hampered by uncharacterised metagenome species and lack of metabolic annotation. To address this, we present a comprehensive computational platform for population stratification based on microbiome composition, the underlying metabolic potential and generation of metagenome species and community level metabolic models. We revisit the concepts of enterotype and microbiome richness introducing the reactobiome as a stratification method to unravel the metabolic features of the human gut microbiome. The reactobiome encapsulates resilience and microbiome dysbiosis at a functional level. We describe five reactotypes in healthy populations from 16 countries, with specific amino acid, carbohydrate and xenobiotic metabolic features. The validity of the approach was tested to unravel host-microbiome and environmental interactions by applying the reactobiome analysis on a one-year Swedish longitudinal cohort, integrating gut metagenomics, plasma metabolomics and clinical data.

1 Abstract Background & Aims Gut dysbiosis and inflammation perpetuates loss of gut-barrier integrity (GBI) and pathological bacterial translocation (BT) in cirrhosis, contributing to infection risk. Little is known about gut inflammation in cirrhosis and how this differs in acute decompensation (AD). We developed a novel approach to characterise intestinal immunopathology by quantifying faecal cytokines (FC) and GBI markers. Methods Faeces and plasma were obtained from patients with stable cirrhosis (SC; n=16), AD (n=47), and healthy controls (HC; n=31). A panel of 15 cytokines and GBI markers including intestinal fatty acid-binding protein-2 (FABP2), D-lactate and faecal calprotectin (FCAL) were quantified by electrochemiluminescence/ELISA. Correlations between analytes and clinical metadata with univariate and multivariate analyses were performed. Results Faecal (F) IL-1β, IFNγ, TNFα, IL-21, IL-17A/F and IL-22 were significantly elevated in AD vs SC (q, Graphical abstract The intestinal cytokine microenvironment in cirrhosis primes mucosal immune responses determining inflammatory outcomes. Exacerbated gut mucosal immune responses in acutely decompensated (AD) cirrhosis perpetuate intestinal barrier damage and prevent mucosal healing. Intestinal cytokine profiles are different in pattern and absolute quantity from the classical features of systemic inflammation in AD vs stable cirrhosis. There is an upregulation of T-cell meditated type-1 and type-17 effector faecal cytokines in AD but no increase in either faecal IL-8 or faecal IL-10 which are both innate-like cytokines that are increased in the circulation. Faecal cytokines and markers of gut barrier inflammation (FABP2) and integrity (D-lactate) accurately differentiate between stable cirrhosis and AD., 1 Highlights • The gut microenvironment in cirrhosis primes mucosal and systemic immune responses. • Gut inflammation is challenging to study in cirrhosis with a paucity of targeted assays. • Exacerbated gut immune responses and barrier damage occur in acutely decompensated (AD) cirrhosis. • Gut cytokine profiles in AD have very different patterns to innate-like systemic inflammation. • Upregulation of faecal T-cell meditated type-1 and type-17 effector cytokines occurs in AD. • Faecal cytokines and gut barrier markers accurately differentiate between stable cirrhosis and AD., The gut barrier is crucial in liver cirrhosis in preventing infection-causing bacteria that normally live in the gut from accessing the liver and other organs via the bloodstream. Inflammation affecting the lining of the gut is thought to play an important role in this process and leads to complications seen in cirrhosis due to disturbances of this ‘gut-liver axis’. Gut inflammation is difficult to study in cirrhosis patients without the use of invasive procedures. Most of the current knowledge is therefore based on changes measured in the bloodstream although these are not representative of the local problems happening in the gut itself. This work characterised these processes by measuring different markers in stool samples from patients at different stages of cirrhosis and compared this to healthy people. These markers, when compared to equivalent markers usually measured in blood, were found to be very different in pattern and absolute levels, suggesting that there is significant gut inflammation in cirrhosis related to different immune system pathways to that seen outside of the gut. This provides new insights into gut-specific immune disturbances that predispose to complications of cirrhosis and emphasises that a better understanding of the gut-liver axis is necessary to develop better targeted therapies.

The impact of cochlear implants (CIs) on the development of speech and language skills in deaf children is very well documented. The influence of CIs on the development of other cognitive abilities has been much less well researched and the findings are more variable. This chapter first briefly considers the evidence for changes in overall intellectual ability as demonstrated by global measures of IQ. This is followed by discussion of the evidence on the impact of CIs on the specific cognitive functions of attention, memory, and reasoning, each in terms of both verbal and visual/nonverbal processing. Evidence regarding the behavioral manifestations of these cognitive processes is also reviewed, all from preschool age through to college-age individuals. Finally, the implications for assessment of, and intervention for, differences in cognitive development as a result of cochlear implantation are briefly considered.

Background There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use. Objectives To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives. Design This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking. Results From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice. Limitations Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service. Conclusions Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered. Future work There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions. Study registration This study is registered as PROSPERO CRD42017056273. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

A commonly employed method to determine the function of a particular cell population and to assess its contribution to the overall system in vivo is to selectively deplete that population and observe the effects. Using monoclonal antibodies to deliver toxins to target cells can achieve this with a high degree of efficiency. Here, we describe an in vivo model combining the use of immunotoxins and multidrug resistant (MDR) gene deficient mice so that only MDR deficient cells expressing the target molecule would be depleted while target molecule expressing, but MDR sufficient, cells are spared. This allows targeted depletion at a higher degree of specificity than has been previously achieved. We have applied this technique to study trogocytosis, the intercellular transfer of cell surface molecules, but this principle could also be adapted using technology already available for use in other fields of study.

Cirrhotic portal hypertension is characterised by development of the decompensating events of ascites, encephalopathy, portal hypertensive bleeding and hepatorenal syndrome, which arise in a setting of cirrhosis-associated immune dysfunction (CAID) and define morbidity and prognosis. CAID describes the dichotomous observations that systemic immune cells are primed and display an inflammatory phenotype, while failing to mount robust responses to pathogen challenge. Bacterial infections including spontaneous bacterial peritonitis are common complications of advanced chronic liver disease and can precipitate variceal haemorrhage, hepatorenal syndrome and acute-on-chronic liver failure; they frequently arise from gut-derived organisms and are closely linked with dysbiosis of the commensal intestinal microbiota in advanced chronic liver disease.Here, we review the links between cirrhotic dysbiosis, intestinal barrier dysfunction and deficits of host-microbiome compartmentalisation and mucosal immune homoeostasis that occur in settings of advanced chronic liver disease. We discuss established and emerging therapeutic strategies targeted at restoring intestinal eubiosis, augmenting gut barrier function and ameliorating the mucosal and systemic immune deficits that characterise and define the course of decompensated cirrhosis.

ObjectivesThere is considerable variation in non-conveyance rates between ambulance services in England. The aim was to explore variation in how each ambulance service addressed non-conveyance for calls ending in telephone advice and discharge at scene.DesignA qualitative interview study.SettingTen large regional ambulance services covering 99% of the population in England.ParticipantsBetween four and seven interviewees from each ambulance service including managers, paramedics and healthcare commissioners, totalling 49 interviews.MethodsTelephone semistructured interviews.ResultsThe way interviewees in each ambulance service discussed non-conveyance within their organisation varied for three broad themes. First, ambulance service senior management appeared to set the culture around non-conveyance within an organisation, viewing it either as an opportunity or as a risky endeavour. Although motivation levels to undertake non-conveyance did not appear to be directly affected by the stability of an ambulance service in terms of continuity of leadership and externally assessed quality, this stability could affect the ability of the organisation to innovate to increase non-conveyance rates. Second, descriptions of workforce configuration differed between ambulance services, as well as how this workforce was used, trained and valued. Third, interviewees in each ambulance service described health and social care in the wider emergency and urgent care system differently in terms of availability of services that could facilitate non-conveyance, the amount of collaborative working between health and social care services and the ambulance service and complexity related to the numbers of services and healthcare commissioners with whom they had to work.ConclusionsThis study suggests that factors within and outside the control of ambulance services may contribute to variation in non-conveyance rates. These findings can be tested in a quantitative analysis of factors affecting variation in non-conveyance rates between ambulance services in England.

BackgroundIn recent years, a number of emergency departments (EDs) have closed or have been replaced by another facility such as an urgent care centre. With further reorganisation of EDs expected, this study aimed to provide research evidence to inform the public, the NHS and policy-makers when considering local closures.ObjectiveTo understand the impact of ED closures/downgrades on populations and emergency care providers.DesignA controlled interrupted time series of monthly data to assess changes in the patterns of mortality in local populations and changes in local emergency care service activity and performance, following the closure of type 1 EDs.SettingThe populations of interest were in the resident catchment areas of five EDs that closed between 2009 and 2011 (in Newark, Hemel Hempstead, Bishop Auckland, Hartlepool and Rochdale) and of five control areas.Main outcome measuresThe primary outcome measures were ambulance service incident volumes and times, the number of emergency and urgent care attendances at EDs, the number of emergency hospital admissions, mortality, and case fatality ratios.Data sourcesData were sourced from the Office for National Statistics, Hospital Episode Statistics (HES) accident and emergency, HES admitted patient care and ambulance service computer-aided dispatch records.ResultsThere was significant heterogeneity among sites in the results for most of the outcome measures, but the overall findings were as follows: there is evidence of an increase, on average, in the total number of incidents attended by an ambulance following 999 calls, and those categorised as potentially serious emergency incidents; there is no statistically reliable evidence of changes in the number of attendances at emergency or urgent care services or emergency hospital admissions; there is no statistically reliable evidence of any change in the number of deaths from a set of emergency conditions following the ED closure in any site, although, on average, there was a small increase in an indicator of the ‘risk of death’ in the closure areas compared with the control areas.LimitationsUnavailable or unreliable data hindered some of the analysis regarding ED and ambulance service performance.ConclusionsOverall, across the five areas studied, there was no statistically reliable evidence that the reorganisation of emergency care was associated with an increase in population mortality. This suggests that any negative effects caused by increased journey time to the ED can be offset by other factors; for example, if other new services are introduced and care becomes more effective than it used to be, or if the care received at the now-nearest hospital is more effective than that provided at the hospital where the ED closed. However, there may be implications of reorganisation for NHS emergency care providers, with ambulance services appearing to experience a greater burden.Future workUnderstanding why effects vary between sites is necessary. It is also necessary to understand the impact on patient experience. Economic evaluation to understand the cost implications of such reorganisation is also desirable.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Introduction: Intrahepatic cholestasis of pregnancy is characterised by pruritus and elevated serum bile acids. The pruritus can be severe, and pharmacological options achieve inconsistent symptomatic improvement. Raised bile acids are linearly associated with adverse fetal outcomes, with existing management of limited benefit. We hypothesised that therapeutic plasma exchange removes pruritogens and lowers total bile acid concentrations, and improves symptoms and biochemical abnormalities in severe cases that have not responded to other treatments. Methods: Four women with severe pruritus and hypercholanemia were managed with therapeutic plasma exchange. Serial blood biochemistry and visual analogue scores of itch severity were obtained. Blood and waste plasma samples were collected before and after exchange; individual bile acids and sulfated progesterone metabolites were measured with HPLC-MS, autotaxin activity and cytokine profiles with enzymatic methods. Results were analysed using segmental linear regression to describe longitudinal trends, and ratio t tests. Results: Total bile acids and visual analogue itch scores demonstrated trends to transiently improve following plasma exchange, with temporary symptomatic benefit reported. Individual bile acids (excluding the drug ursodeoxycholic acid), and the sulfated metabolites of progesterone reduced following exchange (P =.03 and P =.04, respectively), whilst analysis of waste plasma demonstrated removal of autotaxin and cytokines. Conclusions: Therapeutic plasma exchange can lower potentially harmful bile acids and improve itch, likely secondary to the demonstrated removal of pruritogens. However, the limited current experience and potential complications, along with minimal sustained symptomatic benefit, restrict its current use to women with the most severe disease for whom other treatment options have been exhausted.

Aim Ambulance services are experiencing increasing volumes of emergency calls. In response, they have increased the proportion of patients not conveyed to an emergency department (ED). Alternatives to transporting patients to an ED include the provision of telephone advice only, treatment at the scene, or transport to another facility. Variation in the rates of different types of non-conveyance (NC), and in NC overall, exists between ambulance services in England. We explored variability in perceptions of the organisational culture within each individual ambulance service and show this in the context of NC rates. Method We undertook 50 qualitative telephone interviews with ambulance service providers and commissioners in the 10 larger ambulance services in England, to identify factors that may explain variation in rates of ambulance NC. Data was analysed using a Framework model. Results Amongst interviewees there was variation in the perceptions they held regarding the organisational culture of the ambulance service which they were employed by. Recent management restructuring within the ambulance service, perception of management support across the organisation, motivation of the organisation to undertake NC, and perceptions of support for staff undertaking NC varied across the ambulance services. There appeared to be a relationship between some of these factors and NC rates. Conclusion Organisational culture is a complex issue but one which is potentially modifiable. Building a greater understanding of ambulance service organisational culture and how this relates to ambulance NC may help identify ways of improving service delivery across all ambulance services. Conflict of interest None Funding National Institute for Health Research (NIHR) Health Services and Delivery Research Programme.

Aim In England in 2017ambulance services responded to around 11 million calls. Half of patients were not transported to hospital. 11% received telephone advice only and 38% were discharged at scene. For the ten large regional ambulance services, rates of calls ending in telephone advice varied between 5% and 17%. Rates of discharge at scene varied between 23% and 51%. The aim was to explain variation in non-conveyance rates between ambulance services Method A sequential mixed methods study: a qualitative interview study of managers and paramedics (totalling 49 interviews) followed by analysis of one month of routine data from each ambulance service (6 15 618 calls). Results Interviewees identified factors they perceived affected non-transport. Rates of discharge at scene were associated with patient-level factors e.g. age, deprivation and skill level of attending crew. However, variation between ambulance services remained after adjustment for patient-level factors. Variation was explained by ambulance service-level factors:% of calls attended by paramedics with extended skills (odds ratio 1.05 (95% CI: 1.04 to 1.07)), the perception of ambulance service staff that paramedics with extended skills were established and valued within the workforce (odds ratio 1.84 (1.45, 2.33), and the perception of ambulance service staff that senior management was risk averse regarding non-conveyance within an ambulance service (odds ratio 0.78 (0.63, 0.98)). Conclusion Ambulance service management can take actions to reduce a variation in practice. Conflict of interest None Funding National Institute of Health Research.

The mouse heterotopic cardiac transplantation model has been used extensively by investigators in the field of organ transplantation to study the rejection process, test new antirejection treatments, tolerance induction protocols or to understand basic immunological principles. Due to its extensive use, any small refinement of the technique would have a major impact on replacement, reduction and refinement (commonly known as the 3Rs). Here, we describe a novel approach to refine this model. The donor aorta and pulmonary artery are anastomosed peripherally to the femoral artery and vein of the recipient, respectively. The technical success rate is comparable to the conventional abdominal site, but it avoids a laparotomy and handling of the bowels making it less invasive method. As a result, recipients recover faster and require less postoperative analgesia. It is a major refinement under one of the 3Rs and would represent an advance in animal welfare in scientific research.

BACKGROUND: It is estimated that between 3% and 15% of patients have a negative experience of psychotherapy, but little is understood about this. AIMS: The aim of this study was to investigate the factors associated with patients' negative therapy experiences. METHOD: The data comprised 185 patient and 304 therapist questionnaires, 20 patient and 20 therapist interviews. Patients reported on an unhelpful or harmful experience of therapy, and therapists on a therapy where they thought the patient they were working with had a poor or harmful experience. These were transcribed and analysed using thematic analysis. RESULTS: There was a Lack of fit between Patient needs, Therapist skills, and Service structures. This could result in Fault Lines, a tension between Safety and containment and Power and control. This tension led to Strain and Poor Engagement, which led to Consequences following the negative therapy experience. CONCLUSIONS: Patients require clear information, choice, involvement in decision-making, explicit contracting and clarity about sessions and progress. Opportunities for patient feedback should be the norm, where the therapist and service are vigilant for signs of deterioration and solutions considered. Clinical and methodological significance of this article: Estimates of "unwanted effects," including long-lasting effects, of psychotherapy have ranged from 3% to 15%. Few empirical studies have been conducted in this area. This study aimed to address this gap and provide clinicians with a model of risk factors for negative therapy effects. The findings of this study indicate the importance of providing patients with a supportive service structure that offers clear information, choice and involvement in decision-making. Explicit contracting at the beginning of therapy and clarity about sessions and progress are also important in managing patient expectations throughout. Opportunities for patient feedback should be provided.

Sclerostin antibody (Scl-Ab) is a novel bone-forming agent that is currently undergoing preclinical and clinical testing. Scl-Ab treatment is known to dramatically increase bone mass, but little is known about the quality of the bone formed during treatment. In the current study, global mineralization of bone matrix in rats and nonhuman primates treated with vehicle or Scl-Ab was assayed by backscattered scanning electron microscopy (bSEM) to quantify the bone mineral density distribution (BMDD). Additionally, fluorochrome labeling allowed tissue age–specific measurements to be made in the primate model with Fourier-transform infrared microspectroscopy to determine the kinetics of mineralization, carbonate substitution, crystallinity, and collagen cross-linking. Despite up to 54% increases in the bone volume after Scl-Ab treatment, the mean global mineralization of trabecular and cortical bone was unaffected in both animal models investigated. However, there were two subtle changes in the BMDD after Scl-Ab treatment in the primate trabecular bone, including an increase in the number of pixels with a low mineralization value (Z5) and a decrease in the standard deviation of the distribution. Tissue age–specific measurements in the primate model showed that Scl-Ab treatment did not affect the mineral-to-matrix ratio, crystallinity, or collagen cross-linking in the endocortical, intracortical, or trabecular compartments. Scl-Ab treatment was associated with a nonsignificant trend toward accelerated mineralization intracortically and a nearly 10% increase in carbonate substitution for tissue older than 2 weeks in the trabecular compartment (p

BackgroundIn recent years a number of Emergency Departments (EDs) in England have closed, or been replaced by a lower acuity facility such as an Urgent Care Centre. With further re-organisation of EDs expected, the ‘closED’ study aimed to provide research evidence to inform the public, NHS, and policymakers when considering future closures. Our aim was to understand the impact of ED closure on populations and emergency care providers, the first study to do so in England. In this session I will focus on the impact on the ambulance service.MethodsWe undertook a controlled interrupted time series analysis assessing changes in ambulance service activity, following the closure of Type 1 EDs in England. Data was sourced data from Ambulance service computer-assisted dispatch (CAD) records. The resident catchment populations of five EDs, closed between 2009 and 2011, were selected for analysis. Five control areas were also selected. The primary ambulance outcome measures were: ambulance service incident volumes and mean ‘call to destination’ time.ResultsThere was some evidence of a large increase of 13.9% [95% confidence interval (CI) 3.5% to 24.4%] in the total number of emergency ambulance incidents compared with the control areas. There was an increase of 3.9 minutes (95% CI 2.2 to 5.6 minutes) in the meantime taken from a 999 ‘red’ call being answered to a patient arriving at hospital.ConclusionsGiven such major reorganisation of emergency and urgent care we might expect some changes in emergency and urgency care activity. Our study found some changes in the ambulance service measures. The increase in emergency ambulance incidents, over and above the increase in the control area, suggests that the closure of the EDs in our study may have contributed to an additional increase in workload within the ambulance services in these areas.

BackgroundAround 10% of calls to ambulance services in England are resolved over the phone (referred to as telephone advice or hear and treat). These calls are generally dealt with by clinicians following initial call-handler assessment. A systematic review concluded that telephone advice is a safe alternative for patients categorised as low priority but recommended the need to understand the skills required. Our research explores the non-technical skills (cognitive, social and personal) required.MethodsNon-participant observation of telephone advice in three ambulance services involved 40 hours of observation per service, (total n=27 clinicians and 20 call-handlers) and semi-structured interviews with clinicians (n=7), call-handlers (n=7) and managers (n=3). A framework approach and NVIVO qualitative data analysis software were used to analyse the data.FindingsSituation awareness was a necessary skill in gathering information by telephone. Strategies included visualisation, attending to tone of voice and listening to Background noise. Decision making skill was needed to select an appropriate course of action. For clinicians this involved reference to prior experience and risk judgement that the available information supported a safe decision. Call-handlers were more reliant on computerised triage systems. Communication skill required rephrasing technical questions, providing reassurance and assertiveness in managing expectations. Call-handlers had less discretion to rephrase computerised scripts. Personal resources were required to manage role demands that included dealing with high call volumes, task conflict and difficult conversations with callers expecting an ambulance response.ConclusionsThe findings have implications for the recruitment, training and ongoing development of call-handlers and clinicians involved in the delivery of telephone advice. There is scope for further research to provide a more detailed understanding of non-technical skills in the delivery of telephone advice to ensure the consistent delivery of appropriate and safe care that is acceptable to patients.

Background NICE guidelines state cognitive behavioural therapy (CBT) is a front-line psychological treatment for people presenting with depression in primary care. Counselling for Depression (CfD), a form of Person-Centred Experiential therapy, is also offered within Improving Access to Psychological Therapies (IAPT) services for moderate depression but its effectiveness for severe depression has not been investigated. A full-scale randomised controlled trial to determine the efficacy and cost-effectiveness of CfD is required. Methods PRaCTICED is a two-arm, parallel group, non-inferiority randomised controlled trial comparing CfD against CBT. It is embedded within the local IAPT service using a stepped care service delivery model where CBT and CfD are routinely offered at step 3. Trial inclusion criteria comprise patients aged 18 years or over, wishing to work on their depression, judged to require a step 3 intervention, and meeting an ICD-10 diagnosis of moderate or severe depression. Patients are randomised using a centralised, web-based system to CfD or CBT with each treatment being delivered up to a maximum 20 sessions. Both interventions are manualised with treatment fidelity tested via supervision and random sampling of sessions using adherence/competency scales. The primary outcome measure is the Patient Health Questionnaire-9 collected at baseline, 6 and 12 months. Secondary outcome measures tap depression, generic psychological distress, anxiety, functioning and quality of life. Cost-effectiveness is determined by a patient service receipt questionnaire. Exit interviews are conducted with patients by research assessors blind to treatment allocation. The trial requires 500 patients (250 per arm) to test the non-inferiority hypothesis of −2 PHQ-9 points at the one-sided, 2.5% significance level with 90% power, assuming no underlying difference and a standard deviation of 6.9. The primary analysis will be undertaken on all patients randomised (intent to treat) alongside per-protocol and complier-average causal effect analyses as recommended by the extension to the CONSORT statement for non-inferiority trials. Discussion This large-scale trial utilises routinely collected outcome data as well as specific trial data to provide evidence of the comparative efficacy and cost-effectiveness of Counselling for Depression compared with Cognitive Behaviour Therapy as delivered within the UK government’s Improving Access to Psychological Therapies initiative. Trial registration Controlled Trials ISRCTN Registry, ISRCTN06461651. Registered on 14 September 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1834-6) contains supplementary material, which is available to authorized users.

Background: Cardiac transplantation is an excellent treatment for end-stage heart disease. However, rejection of the donor graft, in particular, by chronic rejection leading to cardiac allograft vasculopathy, remains a major cause of graft loss. The lymphatic system plays a crucial role in the alloimmune response, facilitating trafficking of antigen-presenting cells to draining lymph nodes. The encounter of antigen-presenting cells with T lymphocytes in secondary lymphoid organs is essential for the initiation of alloimmunity. Donor lymphatic vessels are not anastomosed to that of the recipient during transplantation. The pathophysiology of lymphatic disruption is unknown, and whether this disruption enhances or hinders the alloimmune responses is unclear. Although histological analysis of lymphatic vessels in donor grafts can yield information on the structure of the lymphatics, the function following cardiac transplantation is poorly understood. Methods: Using single-photon emission computed tomography/computed tomography lymphoscintigraphy, we quantified the lymphatic flow index following heterotrophic cardiac transplantation in a murine model of chronic rejection. Results: Ten weeks following transplantation of a minor antigen (HY) sex-mismatched heart graft, the lymphatic flow index was significantly increased in comparison with sex-matched controls. Furthermore, the enhanced lymphatic flow index correlated with an increase in donor cells in the mediastinal draining lymph nodes; increased lymphatic vessel area; and graft infiltration of CD4 + , CD8 + T cells, and CD68 + macrophages. Conclusions: Chronic rejection results in increased lymphatic flow from the donor graft to draining lymph nodes, which may be a factor in promoting cellular trafficking, alloimmunity, and cardiac allograft vasculopathy.

Although empyema affects more than 65,000 people each year in the United States and in the United Kingdom, there are limited data on the pathogenesis of pleural infection. We investigated the pathogenesis of empyema using animal and cell culture models of Streptococcus pneumoniae infection. The pathological processes during the development of empyema associated with murine pneumonia due to S. pneumoniae (strain D39) were investigated. Lungs were examined using histology, and pleural fluid and blood bacterial colony-forming units, cytokine levels, and cellular infiltrate were determined over time. Bacterial migration across mesothelial monolayers was investigated using cell culture techniques, flow cytometry, and confocal microscopy. After intranasal inoculation with 10(7) S. pneumoniae D39 strain, mice developed pneumonia associated with rapid bacterial invasion of the pleural space; raised intrapleural IL-8, VEGF, MCP-1, and TNF-α levels; and caused significant intrapleural neutrophilia followed by the development of fibrinous pleural adhesions. Bacterial clearance from the pleural space was poor, and in vitro assays demonstrated that S. pneumoniae crossed mesothelial layers by translocation through cells rather than by a paracellular route. This study describes key events during the development of S. pneumoniae empyema using a novel murine model of pneumonia-associated empyema that closely mimics human disease. The model allows for future assessment of molecular mechanisms involved in the development of empyema and evaluation of potential new therapies. The data suggest that transmigration of bacteria through mesothelial cells could be important in empyema development. Furthermore, upon entry the pleural cavity offers a protected compartment for the bacteria.

Although the importance of alveolar macrophages for host immunity during early Streptococcus pneumoniae lung infection is well established, the contribution and relative importance of other innate immunity mechanisms and of bacterial factors are less clear. We have used a murine model of S. pneumoniae early lung infection with wild-type, unencapsulated, and para -amino benzoic acid auxotroph mutant TIGR4 strains to assess the effects of inoculum size, bacterial replication, capsule, and alveolar macrophage-dependent and -independent clearance mechanisms on bacterial persistence within the lungs. Alveolar macrophage-dependent and -independent (calculated indirectly) clearance half-lives and bacterial replication doubling times were estimated using a mathematical model. In this model, after infection with a high-dose inoculum of encapsulated S. pneumoniae , alveolar macrophage-independent clearance mechanisms were dominant, with a clearance half-life of 24 min compared to 135 min for alveolar macrophage-dependent clearance. In addition, after a high-dose inoculum, successful lung infection required rapid bacterial replication, with an estimated S. pneumoniae doubling time of 16 min. The capsule had wide effects on early lung clearance mechanisms, with reduced half-lives of 14 min for alveolar macrophage-independent and 31 min for alveolar macrophage-dependent clearance of unencapsulated bacteria. In contrast, with a lower-dose inoculum, the bacterial doubling time increased to 56 min and the S. pneumoniae alveolar macrophage-dependent clearance half-life improved to 42 min and was largely unaffected by the capsule. These data demonstrate the large effects of bacterial factors (inoculum size, the capsule, and rapid replication) and alveolar macrophage-independent clearance mechanisms during early lung infection with S. pneumoniae .

Background Ambulance services are experiencing increasing demand for response to emergency calls. In response, they have increased the proportion of patients not conveyed to an emergency department (ED). Alternatives to transporting patients to an ED include the provision of telephone advice only (‘hear and treat’), treatment at the scene (‘see and treat’) and transport to another facility (‘see and convey elsewhere’). There is considerable variation in the rates of different types of non-conveyance, and in non-conveyance overall, between ambulance services in England. Understanding of the reasons for this variation has been limited and relatively unexplored. We will explore if there is variability in perceptions of the organisational culture within each individual ambulance service and show this in the context of non conveyance rates. Methods We undertook 50 qualitative telephone interviews with ambulance service providers and commissioners in the 10 larger ambulance services in England, to identify factors that may explain variation in rates of ambulance non-conveyance. Data was analysed using a Framework model. Results Amongst interviewees there was variation in the perceptions they held regarding the organisational culture of the ambulance service which they were employed by. Recent management restructuring within the ambulance service, perception of management support across the organisation, motivation of the organisation to undertake non conveyance, and perceptions of support for staff undertaking non conveyance varied across the 10 ambulance services. We will present this qualitative data alongside routine data identifying non conveyance rates in each service, and explore whether organisational culture appears to be related to ambulance non conveyance rates. Implications Organisational culture is a complex issue but one which is potentially modifiable. Building a greater understanding of ambulance service organisational culture and how this relates to ambulance non conveyance may help identify ways of improving service delivery across all ambulance services.

Sclerostin antibody (Scl-Ab) is a novel bone-forming agent that is currently undergoing preclinical and clinical testing. Scl-Ab treatment is known to dramatically increase bone mass, but little is known about the quality of the bone formed during treatment. In the current study, global mineralization of bone matrix in rats and nonhuman primates treated with vehicle or Scl-Ab was assayed by backscattered scanning electron microscopy (bSEM) to quantify the bone mineral density distribution (BMDD). Additionally, fluorochrome labeling allowed tissue age-specific measurements to be made in the primate model with Fourier-transform infrared microspectroscopy to determine the kinetics of mineralization, carbonate substitution, crystallinity, and collagen cross-linking. Despite up to 54% increases in the bone volume after Scl-Ab treatment, the mean global mineralization of trabecular and cortical bone was unaffected in both animal models investigated. However, there were two subtle changes in the BMDD after Scl-Ab treatment in the primate trabecular bone, including an increase in the number of pixels with a low mineralization value (Z5) and a decrease in the standard deviation of the distribution. Tissue age-specific measurements in the primate model showed that Scl-Ab treatment did not affect the mineral-to-matrix ratio, crystallinity, or collagen cross-linking in the endocortical, intracortical, or trabecular compartments. Scl-Ab treatment was associated with a nonsignificant trend toward accelerated mineralization intracortically and a nearly 10% increase in carbonate substitution for tissue older than 2 weeks in the trabecular compartment (p0.001). These findings suggest that Scl-Ab treatment does not negatively impact bone matrix quality.

Cardiac transplantation is an important form of treatment for patients with end-stage heart failure. Rejection by the immune system of the recipient is a major cause of graft loss. The lymphatic system plays a crucial role in the immune response, but has not received much attention. Donor blood vessels are joined to those of the recipient during the transplant operation; however, due to their small size, donor lymphatic vessels are not reconnected. For this same reason the imaging of lymphatics, and therefore the understanding of this system, has been hampered. In recent years great strides have been made towards developing new imaging modalities that allow the lymphatic system to be imaged in a non-invasive or semi-­invasive manner. Not only does this imaging provide new insights into the lymphatic system, it also presents the possibility of using lymphatic imaging to diagnose and monitor diseases and their treatment. In the case of heart transplantation, which will be the focus of this chapter, the lymphatic system has been shown to play a role in the alloimmune response. Imaging may be used as an extra tool for patient monitoring or as a research tool to develop new treatment protocols for recipients of cardiac transplants.

Background Ambulance services are experiencing increasing demand for response to emergency calls. In response, they have increased the proportion of patients not conveyed to an emergency department (ED). Alternatives to transporting patients to an ED include the provision of telephone advice rather than dispatching a vehicle (‘hear and treat’), treatment at the scene (‘see and treat’) and transport to other facilities (‘see and convey elsewhere’). There is considerable variation in the rates of different types of non-conveyance, and in non-conveyance overall, between ambulance services in England. Understanding the reasons for this variation between services can help identify ways of improving service delivery across all ambulance services. Approaches to commissioning may influence the amount of non-conveyance undertaken in different ambulance services. Methods As part of a larger study we undertook qualitative interviews with ambulance service commissioners (or appropriate commissioning support staff) in the 10 larger ambulance services in England, to identify potential factors that may explain variation in rates of ambulance non-conveyance. 10 commissioners took part in the interviews. Telephone interviews were conducted and transcribed verbatim. Framework analysis was used to analyse the data. Results Ambulance commissioners reported a range of successes and challenges in relation to commissioning non-conveyance services. Successes often related to engaging, collaborative and motivational working relationships between the commissioner and the ambulance service. A range of challenges were reported including access to information to enable decision making, the scale of the geographical commissioning area, collaborative working, complexity, lack of resource and their role as quality enforcers and reporters. There was variation in how different commissioners reported their approaches to commissioning for non-conveyance. Conclusions These findings highlight the challenges facing commissioners. This variation in commissioning approaches will be included in a wider model of factors affecting variation in non-conveyance.

Cognitive biases are increasingly implicated as vulnerability factors in emotional and physical disorders. This issue is examined here in chronic pain sufferers using a recall memory paradigm. A sample of chronic pelvic pain patients undergoing hysterectomy and oophorectomy were assessed prior to the intervention, 8 weeks post-surgery, and again 6 months post-surgery. On each occasion patients were aurally presented four mixed lists of sensory, affective, neutral and gardening words, matched for frequency and length. No difference in the recall of neutral and gardening words was found, suggesting that selective memory for pain-related information cannot be attributed to superior recall of words belonging to a common semantic category. A clear pattern of more pain-related words being remembered before surgery, but better recall of non-pain-related words 6 months post-surgery when pain intensity ratings are significantly reduced, was evidenced. These results suggest that selective memory for pain-related words is more likely to be a secondary consequence of the long term experience of pain than a stable, enduring cognitive vulnerability factor.

Background: Enterotoxin-producing Staphylococcus aureus may cause severe inflammatory intestinal disease, particularly in infants or immunodeficient or elderly patients. They are also recognized to be associated with sudden infant death syndrome. Little is known, however, about mucosal responses to staphylococci. Methods: The mucosal lesion in three infants with staphylococcal enterocolitis was assessed by immunohistochemistry and electron microscopy. The organisms underwent extensive molecular analysis. Their toxins were assessed for capacity to induce T-cell activation and host mucosal responses examined by in vitro organ culture. Epithelial responses were studied by coculture with HEp-2 and Caco-2 cells. Results: Intestinal biopsies from the patients showed marked epithelial damage with mucosal inflammation. The three staphylococci, representing two distinct clones, were methicillin-sensitive, producing SEG/I enterotoxins and Rho-inactivating EDIN toxins. Their enterotoxins potently activated T cells, but only whole organisms could induce in vitro enteropathy, characterized by remarkable epithelial desquamation uninhibited by tacrolimus. EDIN-producing staphylococci, but not their supernatants, induced striking cytopathy in HEp-2 epithelial cells but not in Caco-2 cells. Although HEp-2 and Caco-2 cells produced similar IL-8, CCL20, and cathelicidin LL37 responses upon bacterial exposure, only Caco-2 cells expressed mRNA for the β-defensins HBD2 and HBD3, while HEp-2 cells were unable to do so. Conclusions: Staphylococci induce enterocolitis by a combination of direct enterocyte cytopathy mediated by EDIN toxins, disrupting the epithelial barrier, and enterotoxin superantigen-induced mucosal T-cell activation. Gut epithelial production of β-defensins may contribute to host defense against invasive staphylococcal disease. (Inflamm Bowel Dis 2011;)

BackgroundEnteropathogenic (EPEC) and Enteroaggregative (EAEC) E. coli have similar, but distinct clinical symptoms and modes of pathogenesis. Nevertheless when they infect the gastrointestinal tract, it is thought that their flagellin causes IL-8 release leading to neutrophil recruitment and gastroenteritis. However, this may not be the whole story as the effect of bacterial adherence to IEC innate response(s) remains unclear. Therefore, we have characterized which bacterial motifs contribute to the innate epithelial response to EPEC and EAEC, using a range of EPEC and EAEC isogenic mutant strains.MethodologyCaco-2 and HEp-2 cell lines were exposed to prototypical EPEC strain E2348/69 or EAEC strain O42, in addition to a range of isogenic mutant strains. E69 [LPS, non-motile, non-adherent, type three secretion system (TTSS) negative, signalling negative] or O42 [non-motile, non-adherent]. IL-8 and CCL20 protein secretion was measured. Bacterial surface structures were assessed by negative staining Transmission Electron Microscopy. The Fluorescent-actin staining test was carried out to determine bacterial adherence.ResultsPrevious studies have reported a balance between the host pro-inflammatory response and microbial suppression of this response. In our system an overall balance towards the host pro-inflammatory response is seen with the E69 WT and to a greater extent O42 WT, which is in fit with clinical symptoms. On removal of the external EPEC structures flagella, LPS, BFP, EspA and EspC; and EAEC flagella and AAF, the host inflammatory response is reduced. However, removal of E69 lymphostatin increases the host inflammatory response suggesting involvement in the bacterial mediated anti-inflammatory response.ConclusionEpithelial responses were due to combinations of bacterial agonists, with host-bacterial contact a key determinant of these innate responses. Host epithelial recognition was offset by the microbe's ability to down-regulate the inflammatory response. Understanding the complexity of this host-microbial balance will contribute to improved vaccine design for infectious gastroenteritis.

Background: Human ex vivo evidence indicating that an inappropriate immune response(s) to nonpathogenic bacteria contributes to disease pathogenesis in pediatric Crohn's disease (CD) is limited. The aim of the present study was to compare and contrast the early innate immune response of pediatric "healthy'' versus CD mucosa to pathogenic, probiotic, and commensal bacteria. Methods: "Healthy control'' and CD pediatric mucosal biopsies (terminal ileum and transverse colon) were cocultured for 8 hours with E. coli O42, Lactobacillus GG (LGG), Bacteroides thetaiotaomicron (B. theta), or stimulated with interleukin (IL)-1 beta (positive control). Matched nonstimulated biopsies served as experimental controls. IL-8 was the immune marker of choice. IL-8 mRNA and protein levels were quantified by quantitative polymerase chain reaction and sandwich enzyme-linked immunosorbent assay, respectively. Results: IL-8 secretion was observed when control, ileal biopsies were exposed to pathogenic O42 and probiotic LGG, with no response noted to commensal B. theta. In comparison, Crohn's ileal biopsies showed impaired ability to induce IL-8 in response to O42 and LGG. Control colonic tissue showed a limited response to O42 or B. theta and LGG significantly reduced IL-8 secretion. Unlike control tissue, however, Crohn's ileal and colonic tissue did respond to B. theta, with more enhanced expression in the colon. Conclusions: We provide the first ex vivo data to support the notion that aberrant mucosal recognition of commensal bacteria may contribute to pediatric CD. While IL-8 responses to O42 and LGG varied with disease status and anatomical location, B. theta consistently induced significant IL-8 both in ileal and colonic CD tissue, which was not seen in control, healthy tissue. (Inflamm Bowel Dis 2011;17:1201-1208)

BackgroundCampylobacter jejuni is the most prevalent cause of bacterial gastroenteritis worldwide. Despite the significant health burden this infection presents, molecular understanding of C. jejuni-mediated disease pathogenesis remains poorly defined. Here, we report the characterisation of the early, innate immune response to C. jejuni using an ex-vivo human gut model of infection. Secondly, impact of bacterial-driven dendritic cell activation on T-cell mediated immunity was also sought.MethodologyHealthy, control paediatric terminal ileum or colonic biopsy tissue was infected with C. jejuni for 8-12 hours. Bacterial colonisation was followed by confocal microscopy and mucosal innate immune responses measured by ELISA. Marked induction of IFNγ with modest increase in IL-22 and IL-17A was noted. Increased mucosal IL-12, IL-23, IL-1β and IL-6 were indicative of a cytokine milieu that may modulate subsequent T-cell mediated immunity. C. jejuni-driven human monocyte-derived dendritic cell activation was followed by analyses of T cell immune responses utilising flow cytometry and ELISA. Significant increase in Th-17, Th-1 and Th-17/Th-1 double-positive cells and corresponding cytokines was observed. The ability of IFNγ, IL-22 and IL-17 cytokines to exert host defence via modulation of C. jejuni adhesion and invasion to intestinal epithelia was measured by standard gentamicin protection assay.ConclusionsBoth innate and adaptive T cell-immunity to C. jejuni infection led to the release of IFNγ, IL-22 and IL-17A; suggesting a critical role for this cytokine triad in establishing host anti-microbial immunity during the acute and effectors phase of infection. In addition, to their known anti-microbial functions; IL-17A and IL-17F reduced the number of intracellular C. jejuni in intestinal epithelia, highlighting a novel aspect of how IL-17 family members may contribute to protective immunity against C. jejuni.

This paper reports the development and validation of the Pain Beliefs Questionnaire (PBQ). This is a 20-item questionnaire covering beliefs about the cause and treatment of pain. It was administered to 294 subjects, comprising 100 chronic pain patients and 194 controls. An exploratory factor analysis revealed 2 factors accounting for 68.15% of the variance. From the final solution 2 scales were derived: the first called Organic Beliefs and the second Psychological Beliefs scale, comprising 8 and 4 items, respectively. The construct validity of the questionnaire was assessed in 2 ways. First, the responses of chronic pain patients and non-patient controls were compared: a significant difference (F(1,236) = 53.04, P < 0.0001) between these 2 groups emerged such that chronic pain patients were more likely to endorse the Organic Beliefs scale items, whereas non-patients were more likely to endorse the Psychological Beliefs scale items. Secondly, as predicted significant associations were observed between scores on the Organic Beliefs scale and scores on the Chance and Powerful Others scales of the Multidimensional Health Locus of Control (MHLC), and also between the Psychological Beliefs and Internal scales of the MHLC. No relationship, however, emerged between these scales and measures of pain intensity. The implications of these findings for the assessment and management of chronic pain patients, and in the understanding of the development of chronic pain, are discussed.

Objective—To determine whether specific treadmill exercise regimens would accelerate age-related changes in collagen fibril diameter distributions in the common digital extensor tendon (CDET) of the forelimbs of young Thoroughbreds. Animals—24 female Thoroughbreds. Procedure—Horses were trained for 18 weeks (6 horses; short term) or 18 months (5 horses; long term) on a high-speed treadmill; 2 age-matched control groups (6 horses/group) performed walking exercise only. Horses were (mean ± SD) 24 ± 1 months and 39 ± 1 months old at termination of the shortterm and long-term regimens, respectively. Midmetacarpal CDET specimens were obtained and processed for transmission electron microscopy. Diameter and area of at least 1,000 collagen fibrils/specimen were measured by use of computerized image analysis. Mass-average diameter (MAD) of collagen fibrils and collagen fibril index were calculated for each horse. Results—Collagen fibril MAD for the older horses was significantly less than that for the younger horses. Exercise did not significantly affect fibril diameter or distributions in either age group, and collagen fibril index did not differ significantly between groups. Conclusions and Clinical Relevance—Age-related reduction in collagen fibril MAD agreed with findings for other tendons and species. Training did not accelerate age-related change in the CDET, in contrast to a reported decrease in collagen fibril MAD in the superficial digital flexor tendon of horses trained long term. Our results support the concept that the functionally distinct nature of the CDET and superficial digital flexor tendon in horses results in fundamentally different responses to high-speed exercise regimens. (Am J Vet Res 2005;66:564–568)