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Endocytosis, an important macromolecule uptake process in cells, is known to be dysregulated in cancer. Clathrin and caveolin-1 proteins play a major role in receptor-mediated endocytosis. We have used a quantitative, unbiased and semi-automated method to measure in situ protein expression of clathrin and caveolin-1 in cancerous and paired normal (cancer adjacent, non-cancerous) human prostate tissue. There was a significant (p N = 29, n = 91) compared to normal tissue (N = 29, n = 67) (N = number of patients, n = number of cores in tissue arrays). Conversely, there was a significant (p

Simple Summary Disorders of bladder function can result from congenital spinal cord developmental defects and can remain in a significant number of patients despite surgical improvements to repair the primary defect. We studied the ability of bladder wall muscle from such patients to contract, a function essential to void collected urine and avoid urinary tract infections and potential damage to the kidneys. Tissue was taken when patients were several years old, at the time of surgical operations to improve bladder function. This tissue would otherwise have been discarded and was collected with the full ethical approval and consent of parents or guardians. We found that the ability of the bladder wall samples to contract was impaired and was generally stiffer; both of which would make it more difficult for the bladder to void urine. These functional changes were associated with a replacement of muscle with connective tissue (fibrosis). The experiments provide a pathway to devise strategies that might improve bladder function in these patients through reversal of the intrinsic tissue pathways that increase fibrosis. Abstract Neurogenic lower urinary tract (NLUT) dysfunction in paediatric patients can arise after congenital or acquired conditions that affect bladder innervation. With some patients, urinary tract dysfunction remains and is more difficult to treat without understanding the pathophysiology. We measured in vitro detrusor smooth muscle function of samples from such bladders and any association with altered Wnt-signalling pathways that contribute to both foetal development and connective tissue deposition. A comparator group was tissue from children with normally functioning bladders. Nerve-mediated and agonist-induced contractile responses and passive stiffness were measured. Histology measured smooth muscle and connective tissue proportions, and multiplex immunohistochemistry recorded expression of protein targets associated with Wnt-signalling pathways. Detrusor from the NLUT group had reduced contractility and greater stiffness, associated with increased connective tissue content. Immunohistochemistry showed no major changes to Wnt-signalling components except down-regulation of c-Myc, a multifunctional regulator of gene transcription. NLUT is a diverse term for several diagnoses that disrupt bladder innervation. While we cannot speculate about the reasons for these pathophysiological changes, their recognition should guide research to understand their ultimate causes and develop strategies to attenuate and even reverse them. The role of changes to the Wnt-signalling pathways was minor.

This focus article describes some of the cardiac anomalies detected in calves submitted to APHA Veterinary Investigation Centres and other postmortem examination providers.

There are substantial inequalities associated with antibiotics and the determinants of their effectiveness, including the risk of exposure to antibiotic-resistant microbes, access to relevant treatment advice, diagnostic facilities, risk of life-threatening infectious disease, and access to antibiotics. Current arrangements (social, political, economic) allow inequalities in the distribution of antibiotic benefits and burdens. This article focuses on the justification of relevant inequalities from a contractualist perspective.

OBJECTIVE: To determine the effects on the vaginal microbiota of an oral probiotic preparation administered from early pregnancy. \ud \ud DESIGN: Randomised, double blind, placebo-controlled trial. \ud \ud SETTING: Four maternity units in the UK. \ud \ud POPULATION: Women aged 16 years or older recruited at 9-14 weeks' gestation. \ud \ud METHODS: Participants were randomly allocated to receive oral capsules of probiotic containing Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 each at 2.5 × 109 colony-forming units (CFUs) or placebo once daily from recruitment until the end of pregnancy. \ud \ud MAIN OUTCOME MEASURE: Rates of bacterial vaginosis (BV, defined as Nugent score ≥7) at 18-20 weeks' gestation compared by logistic regression adjusted for possible confounders. \ud \ud RESULTS: The primary analysis included 78% (238/304) of participants who initially consented (probiotic group 123, placebo group 115). Of these participants, 95% (227/238) reported an intake of 93% or more of the required number of capsules. The rates of BV did not differ between groups at 18-20 weeks' gestation (15% (19/123) in the probiotic group vs. 9% (10/115) in the placebo group, adjusted odds ratio 1.82, 95% confidence interval 0.64-5.19). There were also no differences between the groups in the proportion of women colonised with the probiotic strains, Escherichia coli, Group B streptococci or other vaginal microbiota. There were no differences in the alpha diversity or composition of the bacterial communities between or within the probiotic and placebo groups at 9-14 and 18-20 weeks' gestation. \ud \ud CONCLUSIONS: Oral probiotics taken from early pregnancy did not modify the vaginal microbiota. \ud \ud TWEETABLE ABSTRACT: The oral probiotic preparation used in this study does not prevent BV in pregnant women.

Proposals for SARS-CoV-2 virus vaccination priorities in the UK and in many other countries are heavily influenced by epidemiological models, which use outcome measures such as deaths or hospitalisation. Limiting the values under consideration to those attributable to the direct effects of infection has the advantage of simplifying the models and the process of decision-making. However, the consequences of the pandemic extend beyond outcomes directly attributable to SARS-CoV-2 infection, and include restrictions on educational and work opportunities, access to services, recreational activities, affiliations and relationships with others, freedom of movement (including escaping abusive relationships), and other determinants of human experience. Capability theory gives emphasis to the freedoms that individuals have to express themselves (in doings and beings). Restrictions on freedoms restrict our capabilities. Capability theory has been used to provide a framework for the evaluation and comparison of international development approaches and in the evaluation of public health policy. There is a clustering of disadvantages associated with this pandemic that adds to pre-existing inequalities. Much of the disadvantage engendered in the SARS-CoV-2 pandemic is left out when public health policy is based on a limited range of metrics. Acknowledging the impact of policy across the range of human freedoms at both a national and international level has the potential to improve policy, facilitate the mitigation of direct and indirect adverse consequences, and improve public confidence and the effectiveness of vaccine deployment strategies.

Background and AimsLiver cancer comprises of benign or malignant tumors including hepatocellular carcinoma (HCC), cholangiocarcinoma (CC), hepatoblastoma (HB), and other rarer tumor types. There is evidence of aberrant Wnt signaling during initiation and progression of HCC, CC and HB.MethodsWe investigated the expression of Wnt/β-catenin transcription related proteins, Cyclin D1, c-Myc, Fra-1 and Pygo-1, in human liver tumors by using an unbiased, quantitative immunohistochemical (qIHC) approach.ResultsSemi-automated, unbiased quantitation of individual proteins revealed reduced expression of Cyclin D1 and Pygo-1 in CC (P < 0.0001 and P < 0.01, respectively) and HB (P < 0.05 and P < 0.01, respectively) compared to normal liver (NL). Receiver operating characteristic curves showed Cyclin D1 as a putative marker for CC (AUC > 0.8) that discriminates CC from both NL and HCC (P ≤ 0.0001), and Pygo-1 (AUC > 0.7) as a marker for both CC and HCC (P < 0.01) compared to NL. Combining Cyclin D1/Pygo-1 and applying a logistic regression model further improved the diagnostic potential (classifying 84% of NL and CC cases, P < 0.0001). Quantitative co-localisation of tissue samples simultaneously labeled with the four biomarkers, indicated that co-localisation of both Pygo-1/Fra-1 and c-Myc/Fra-1 was also significantly changed in CC and HCC (P < 0.0001) vs NL. Additionally, co-localisation of Pygo-1/Fra-1, in particular, could also distinguish CC from HCC (P < 0.05).ConclusionOur results indicate that measurement of Wnt signaling markers could be used to stratify liver cancer.

The expression of c-fos mRNA is an indirect marker of neuronal activity. RNAscope ACD Bio RNAscope (now Biotechne) is a proprietary in-situ mRNA detection technology using branched DNA amplification and z paired probes to deliver a robust and specific assay designed primarily for use on formalin fixed paraffin sections [1]. In the present study we adapted this technology to be used in frozen sections to allow quantitative analysis of c-fos gene expression in different mouse brain regions during neuropharmacology studies. The method was applied by Cosi et al. 2021 [2] and the image analysis is described here in details. • The patented RNAscope (ACD Bio) flourescent in-situ hybridisation technology designed primarily for use on formalin fixed paraffin sections was adapted to be used on frozen section from mouse brain. • We carefully controlled sample preparation and handling to maximise mRNA preservation and used the fluorescent properties of the fast Red substrate combined with fluorescent whole slide scanning and image analysis. • A customized algorithm was set up for image analysis • The method developed permitted the quantitative analysis of c-fos expression in specific brain regions from whole sections., Graphic abstract Image, graphical abstract

The application of multiplex immunofluorescent detection of proteins, mRNAs, or both in combination has contributed to our understanding of biomarker expression and distribution within normal and pathological diseased tissues. In combination with whole-slide scanning these techniques permit the visualization of multiple biomarkers, their distribution within normal and pathological tissues, and their spatial and proximal distribution to each other in intact tissue sections. The expression of multiple biomarkers can now be used to accurately phenotype specific cell types, e.g., immune cells which rely on the expression of multiple biomarkers for precise identification. The availability of antibody reagents to detect specific protein targets, range of targets in specific technology platforms, and tissue fixation may mean that one technology may not be suitable for visualizing all biomarkers of interest. Here I demonstrate that a mixed multiplex approach for multiple protein and mRNA can be delivered on automated platforms suitable for high-throughput environments, and predict that mixed multiplex approaches will be important in future to compensate for tissue fixation differences, biomarker availability, and technology platform limitations.

Equine penile squamous cell carcinoma (EpSCC) is a relatively common cutaneous neoplasm with a poor prognosis. In this study, we aimed to determine the protein expression and colocalisation of FRA1, c-Myc, Cyclin D1, and MMP7 in normal (NT), tumour (T), hyperplastic epidermis and/or squamous papilloma (Hyp/Pap), poorly-differentiated (PDSCC), or well-differentiated (WDSCC) EpSCC using a tissue array approach. Further objectives were to correlate protein expression to (i) levels of inflammation, using a convolutional neural network (ii) equine papillomavirus 2 (EcPV2) infection, detected using PCR amplification. We found an increase in expression of FRA1 in EpSCC compared to NT samples. c-Myc expression was higher in Hyp/Pap and WDSCC but not PDSCC whereas MMP7 was reduced in WDSCC compared with NT. There was a significant increase in the global intersection coefficient (GIC) of FRA1 with MMP7, c-Myc, and Cyclin D1 in EpSCC. Conversely, GIC for MMP7 with c-Myc was reduced in EpSCC tissue. Inflammation was positively associated with EcPV2 infection in both NT and EpSCC but not Hyp/Pap. Changes in protein expression could be correlated with EcPV2 for Cyclin D1 and c-Myc. Our results evaluate novel biomarkers of EpSCC and a putative correlation between the expression of biomarkers, EcPV2 infection and inflammation.

Summary Introduction Posterior urethral valves (PUV) is the most common cause of congenital bladder outflow obstruction with persistent lower urinary tract and renal morbidities. There is a spectrum of functional bladder disorders ranging from hypertonia to bladder underactivity, but the aetiology of these clinical conditions remains unclear. Aims and objectives We tested the hypothesis that replacement of detrusor muscle with non-muscle cells and excessive deposition of connective tissue is an important factor in bladder dysfunction with PUV. We used isolated detrusor samples from children with PUV and undergoing primary or secondary procedures in comparison to age-matched data from children with functionally normal bladders. In vitro contractile properties, as well as passive stiffness, were measured and matched to histological assessment of muscle and connective tissue. We examined if a major pathway for fibrosis was altered in PUV tissue samples. Methods Isometric contractions were measured in vitro in response to either stimulation of motor nerves to detrusor or exposure to cholinergic and purinergic receptor agonists. Passive mechanical stiffness was measured by rapid stretching of the tissue and recording changes to muscle tension. Histology measured the relative amounts of detrusor muscle and connective tissue. Multiplex quantitative immunofluorescence labelling using five epitope markers was designed to determine cellular pathways, in particular the Wnt-signalling pathway, responsible for any changes to excessive deposition of connective tissue. Results and Discussion PUV tissue showed equally reduced contractile function to efferent nerve stimulation or exposure to contractile agonists. Passive muscle stiffness was increased in PUV tissue samples. The smooth muscle:connective tissue ratio was also diminished and mirrored the reduction of contractile function and the increase of passive stiffness. Immunofluorescence labelling showed in PUV samples increased expression of the matrix metalloproteinase, MMP-7; as well as cyclin-D1 expression suggesting cellular remodelling. However, elements of a fibrosis pathway associated with Wnt-signalling were either reduced (β-catenin) or unchanged (c-Myc). The accumulation of extracellular matrix, containing collagen, will contribute to the reduced contractile performance of the bladder wall. It will also increase tissue stiffness that in vivo would lead to reduced filling compliance. Conclusions Replacement of smooth muscle with fibrosis is a major contributory factor in contractile dysfunction in the hypertonic PUV bladder. This suggests that a potential strategy to restore normal contractile and filling properties is development of the effective use of antifibrotic agents. Download : Download high-res image (132KB) Download : Download full-size image Summary Figure .

Infection and infection-related complications are important causes of death and morbidity following preterm birth. Despite this risk, there is limited understanding of the development of the immune system in those born prematurely, and of how this development is influenced by perinatal factors. Here we prospectively and longitudinally follow a cohort of babies born before 32 weeks of gestation. We demonstrate that preterm babies, including those born extremely prematurely (, The infant immune system is continuously shaped by environmental factors. Here the authors demonstrate that rapid immune development in preterm babies is modulated by perinatal inflammation more than gut microbiota, and that lower CXCL8-producing T cells may identify infants susceptible to infection.

The application of multiplex immunofluorescent detection of proteins, mRNAs, or both in combination has contributed to our understanding of biomarker expression and distribution within normal and pathological diseased tissues. In combination with whole-slide scanning these techniques permit the visualization of multiple biomarkers, their distribution within normal and pathological tissues, and their spatial and proximal distribution to each other in intact tissue sections. The expression of multiple biomarkers can now be used to accurately phenotype specific cell types, e.g., immune cells which rely on the expression of multiple biomarkers for precise identification. The availability of antibody reagents to detect specific protein targets, range of targets in specific technology platforms, and tissue fixation may mean that one technology may not be suitable for visualizing all biomarkers of interest. Here I demonstrate that a mixed multiplex approach for multiple protein and mRNA can be delivered on automated platforms suitable for high-throughput environments, and predict that mixed multiplex approaches will be important in future to compensate for tissue fixation differences, biomarker availability, and technology platform limitations.

Nussbaum’s capability theory by drawing attention to multiple determinants of wellbeing provides a rich and relevant evaluative space for framing antibiotic resistance. I consider the implications of antibiotic resistance for child development and adult capabilities. There are common risk factors for childhood growth stunting and the spread of infectious diseases in both antibiotic sensitive and resistant forms. The interaction between infectious diseases, antibiotic resistance and growth stunting illustrates a clustering of disadvantage. The control of antibiotic resistance requires wide-ranging cooperative action. Cooperation is predicated on an expectation of equitable access to effective antibiotics. This expectation is confounded by inequality both in access to antibiotics, and in the risk that available antibiotics will be ineffective. Securing child development (and adult capabilities) requires that inequalities both in access to antibiotics and in risk factors for the dissemination and transmission of antibiotic resistance are addressed. Inequality undermines the cooperative activity that is control of infectious diseases and compounds the threat to the securing of capabilities that arises from antibiotic resistance.

Background Necrotising enterocolitis (NEC) is a significant cause of infant morbidity and mortality, disproportionately affecting those of extreme prematurity and/or very low birth weight. A number of risk factors have been identified, including an association between the use of antibiotics, and the subsequent development of NEC. Aim This review sought to address whether the choice of antibiotic(s) used to treat infants with suspected late-onset sepsis (LOS) influences the risk of developing NEC. Methods A systematic review was performed across Web of Knowledge, Cochrane Library, Ovid Medline, EMBASE and CINAHL databases, up to February 2018, assessing the primary outcome of NEC occurrence, as extracted directly from the published articles. Studies were included if they were randomised control trials (or featured adequate adjustment for confounders); included clear criteria for defining LOS/NEC; and assessed occurrence of NEC in premature infants treated for LOS with intravenous antibiotics. Studies were excluded if non-original, not exclusively featuring premature infants, or where treatment was given for early-onset sepsis only. Findings 2291 titles and abstracts were identified, of which one study (81 subjects) was suitable for analysis, following screening against eligibility criteria. This suggested a decreased risk of developing definite NEC following treatment with a vancomycin/aztreonam combination, versus a vancomycin/gentamicin regimen (OR = 0·08, 95%CI = 0·00–1·45). Conclusion This systematic review identified one study where the occurrence of NEC was reported in the context of comparing different antibiotic regimens for late onset sepsis and highlights that the type of antibiotic used to treat LOS in preterm infants might be a determinant of the risk of developing NEC. Although it is known that different antibiotic combinations impact the enteric microbiome and that antibiotic exposure is a risk factor for NEC, there is a paucity of well-designed studies that look at the relationship between NEC risk and specific antibiotic exposures.

Periprosthetic fractures of the proximal femur place a significant burden on the patients who endure them, as well as the medical health system that supports them. The purpose of this study was to determine whether femoral cortical thickness, as an absolute measurement, is a predictor of periprosthetic fracture pattern.A cohort of 102 patients who had sustained a periprosthetic hip fracture were retrospectively identified. This included 58 males and 44 females with a mean age of 79.8 years. The femoral periprosthetic fracture pattern was classified based on the Vancouver classification system. Stem fixation was recorded and femoral cortical thickness measured. Patients were grouped into cemented and cementless stems. The relationship between cortical thickness and periprosthetic fracture pattern was assessed using the primary stem fixation method. Receiver operating characteristic (ROC) curve analysis was used to identify a threshold in the cortical thickness that predicted fracture pattern. Multinomial logistic regression analysis was used to adjust for confounding variables to assess the independent influence of cortical thickness on the risk of sustaining a Vancouver type A, B or C.There were 65 (63.7%) patients in the cemented group and 37 (36.3%) in the cementless group. The pattern of periprosthetic fractures around cemented stems was significantly (p 0.001) influenced by the femoral cortical thickness, with a thinner cortical thickness associated with a type A fracture pattern. In contrast, no association between femoral cortical thickness and fracture pattern assessment was demonstrated in the cementless group (p = 0.82 Chi square). Comparing the rate of type A fracture patterns between the groups illustrated a significantly decreased risk in the cemented group with a cortical thickness of 7 mm (odds ratio 0.03, p 0.001). ROC curve analysis of the cemented group demonstrated a threshold value of 6.3 mm, offering a sensitivity of 83.3% and a specificity of 78.9% in predicting an A type fracture. Using this threshold, patients with a cortical thickness of 6.3 mm or less were significantly more likely to sustain a Vancouver type A fracture (OR 18.9, 95% CI 2.0-166.7, p 0.001) when compared to patients with a cortical thickness of 6.3 mm. In contrast, the ROC curve analysis did not find cortical thickness to be a predictor of fracture pattern in the cementless group. When adjusting for confounding variables, multinomial logistic regression demonstrated a cortical thickness of 6.3 mm or less was a significant predictor of a type A fracture (OR 3.28, 95% CI 1.06-10.16, p = 0.04) relative to those sustaining a type B fracture.Cortical thickness was found to influence the periprosthetic fracture pattern around cemented femoral stems, but this was not observed with cementless stems. Type A fracture patterns were significantly more likely to occur with a cortical thickness of 6.3 mm or less around cemented stems.

The microbial dysbiosis associated with necrotizing enterocolitis (NEC) in preterm infants suggests that early exposure to probiotics may decrease and antibiotics may increase NEC risk. However, administration of Bifidobacterium breve strain BBG-001 to preterm infants did not affect NEC incidence in a multicenter randomised controlled phase 3 trial (PiPS trial). Using a subset of these subjects we compared the fecal microbiome of probiotic and placebo groups and assessed the impact of early antibiotic treatment. Extracted DNA from 103 fecal samples collected at 36 weeks post-menstrual age underwent PCR amplification of a fragment of the 16S rRNA gene. Heatmaps were constructed showing the proportions of sequences from bacterial families present at > 1% of the community. Stepwise logistic regression assessed the association between early antibiotic exposure and microbiome group. There was no difference in the microbial richness and diversity of the microbiome of preterm infants following treatment with probiotic or a placebo. Conversely, early antimicrobial exposure was associated with different patterns of colonisation, specifically a relative abundance of Proteobacteria. These findings highlight that the potential influence of probiotics on the microbiome of preterm infants remains unclear whereas the modulatory effect of antibiotic exposure on microbial colonisation requires further research., Highlights • Microbial dysbiosis has been associated with the development of neonatal necrotizing enterocolitis in premature infants. • Early administration of a probiotic compared to a placebo did not alter the microbiome of premature infants. • Early life exposure to antibiotics was associated with different patterns of colonisation in premature infants. The association of altered microbial gastrointestinal colonisation (dysbiosis) with neonatal necrotizing enterocolitis suggests that, through their effects on microbial colonisation, probiotics and antimicrobials may modulate necrotizing enterocolitis risk. We compared microbial colonisation patterns of premature infants administered a probiotic or placebo in the early stages of life. We found no significant effect of probiotic administration on microbial colonisation, a finding which disputes the suggestion that prophylactic use of probiotics prevents the dysbiosis associated with necrotizing enterocolitis. In contrast, antibiotic exposure did alter the pattern of colonisation, indicating the need for further research in order to clearly ascertain the nature of this relationship.

An important consideration in pregnancy is the relationship between infection in the mother and the developing foetus. Infections can indirectly impact the foetus through effects on the mother, for example, maternal urinary tract infection is associated with preterm birth, or can infect the foetus. Routes of infection can be ascending from the birth canal through the cervical os, transplacentally, or rarely, contiguously. The effect on the mother is also important: pregnancy is considered an immunosuppressive state and the growing foetus causes significant mechanical and physiological changes. Although the first trimester is the key developmental phase for the growing foetus, during the third trimester the mother is more susceptible to severe respiratory infection and some viral infections such as varicella zoster virus (VZV), due to the mechanical changes produced by the growing foetus. There is a paucity of evidence supporting the safety of drugs in pregnancy. Use of any medicinal drug in pregnancy, including antibiotics, requires good reasons. The optimum choice of antibiotics depends on the trimester of the pregnancy. In general, beta-lactams are safe and tetracyclines should be avoided throughout pregnancy. Nitrofurantoin is safe until after thirty-five weeks gestation and trimethoprim should be avoided in the first trimester but is safe otherwise (perhaps with folic acid supplementation if < 20 weeks). Specific patterns of colonization and infection of the genitourinary tract can be associated with an increased risk of an adverse pregnancy outcome, particularly preterm birth. Sexually transmitted diseases such as gonorrhoea and chlamydia are associated with an increased risk of spontaneous preterm birth, which may extend to infection in the pre-conception period. Bacterial vaginosis is an abnormal pattern of vaginal colonization and is also linked with an increased risk of preterm birth. The US Center for Disease Control recommends screening all pregnant women for chlamydia, gonorrhoea, syphilis, HIV, and hepatitis B, symptomatic women for trichomonas and genital herpes, women considered at high risk of preterm birth for bacterial vaginosis, and women at high risk of blood-borne virus infection for hepatitis C. Treatment is administered to reduce the risk of an adverse pregnancy outcome (syphilis, gonorrhoea, chlamydia, trichomonas, and bacterial vaginosis) or to prevent transmission to the infant (herpes, HIV, hepatitis B, and C).

A great variety of biomedical devices are used in patient care. Almost all hospitalized patients will have a vascular catheter placed to support administration of drugs, fluids, electrolytes, blood products, feeding solutions, or for haemodynamic monitoring. Many will also be exposed to urinary catheters, or tracheal tubes. There is also increasing use of a variety of prosthetic devices. Different biomedical devices have different infection associations. Examples of associations include cardiac pacemakers with Staphylococcus aureus blood-stream infection, contact lenses with amoebic keratitis, tampons with toxic shock, and historically, intra-uterine devices with pelvic actinomycosis. The most common causative organisms associated with device infections are bacteria (less commonly fungi). For many devices coagulase-negative staphylococci are the most frequent cause of infection. It is important to remember that an enormous range of microbes have been reported to cause device-associated infection. Biomedical devices predispose to infection through a wide range of mechanisms. These may include (depending on the device) traversing of anatomical barriers (such as the skin), protected niches for microbial proliferation, inappropriate immune activation, and provision of a surface(s) for biofilm formation. Few devices are completely inert. Most devices elicit an immune response, which depletes local complement levels and reduces oxidative killing by neutrophils, some directly damage tissues, and some release biologically-active products. There is much interest in the molecular mechanisms and physical interactions that underlie the formation of communal microbial structures on biomaterial surfaces. Many difference strategies have been proposed both to prevent, and to destroy microbial biofilms associated with biomedical devices. Complications associated with devices are most likely to be mechanical or infective. It is estimated that up to 25% of patients with a central venous catheter (CVC) will suffer a serious mechanical or infection related complication. Risk factors for infection include host, device, and operator factors. Extremes of age, co-morbidities such as diabetes, active infection at the time of insertion, and loss of relevant anatomical barriers to infection are host risk factors that apply to most devices. Operator risk factors include poor compliance with insertion or post-insertion ‘best practice’.

This chapter covers infections in neonates and young children. In this chapter the term ‘young children’ indicates children under two years of age. For information on congenital infections interested readers are referred to Chapter 37. Early neonatal infection is variably defined as infection presenting up to a week after birth, but most infections present in the first seventy-two hours. Microbial invasion of the chorio-amniotic membranes or uterine cavity occur in a significant proportion of pregnancies before rupture of membranes (> 50% with preterm birth before thirty weeks gestation, 10% with term delivery), and in the majority of those with prolonged rupture of membranes (> 24 hours). It is likely that the majority of cases of early sepsis arise through ascending infection of the uterus (through the cervical canal). Ascending infection may be important in the pathogenesis of preterm birth and is more common in infants born preterm. Group B Streptococci (GBS) (Streptococcus agalactiae) and Escherichia coli are the most common agents of early neonatal infection. Infection with Listeria monocytogenes probably arises following ingestion of contaminated food by the mother, blood stream infection, and transplacental spread. Early infection with GBS usually presents with respiratory distress and can be difficult to differentiate from respiratory distress associated with other causes, particularly prematurity. The incidence of GBS blood stream infection in England and Wales has been 0.3–0.45/ 1000 live births over the last five years. Maternal genital herpes simplex infection can spread to the newborn infant and cause a wide range of serious clinical presentations, with skin, systemic, and central nervous system involvement. Maternal infection with Neisseria gonorrhoea or Chlamydia trachomatis can also infect the infant. Either can cause conjunctivitis which can sometimes be of sufficient severity to cause substantial damage to the eyes. Gonococcal conjunctivitis usually presents in the first few days of life. Infection with Chlamydia trachomatis (conjunctivitis or pneumonitis) tends to present later. Traditionally, penicillin and an aminoglycoside have been used to treat infants with suspected early sepsis (to cover GBS and Escherichia coli). Newborn infants are often empirically treated because it can be difficult to differentiate early bacterial sepsis from respiratory distress associated with prematurity, and death may ensue rapidly if the infection is not treated.

Summary The roles of tumor-associated macrophages (TAMs) and circulating monocytes in human cancer are poorly understood. Here, we show that monocyte subpopulation distribution and transcriptomes are significantly altered by the presence of endometrial and breast cancer. Furthermore, TAMs from endometrial and breast cancers are transcriptionally distinct from monocytes and their respective tissue-resident macrophages. We identified a breast TAM signature that is highly enriched in aggressive breast cancer subtypes and associated with shorter disease-specific survival. We also identified an auto-regulatory loop between TAMs and cancer cells driven by tumor necrosis factor alpha involving SIGLEC1 and CCL8, which is self-reinforcing through the production of CSF1. Together these data provide direct evidence that monocyte and macrophage transcriptional landscapes are perturbed by cancer, reflecting patient outcomes.

> We have identified a syndrome of diarrhoea and rapid loss of condition affecting dairy calves, which is unresponsive to treatment The farm animal disease surveillance systems in the UK and Ireland have identified a syndrome of diarrhoea and rapid loss of condition affecting dairy …

Healthcare workers (HCWs) carry a substantial risk of harm from infectious disease, particularly, but not exclusively, during outbreaks. More can be done by healthcare institutions to identify risks, quantify the current burden of preventable infectious disease amongst HCWs and identify opportunities for prevention. We suggest that institutional obligations should be clarified with respect to the mitigation of infectious disease risks to staff, and question the duty of HCWs to care while healthcare institutions persist with a reactive rather than proactive attitude to infectious disease threats.

Traditionally, Lisfranc fracture dislocations have been treated with transarticular screw fixation. A more recent development has been the use of dorsal bridging plates. The aim of the present study was to compare the radiologic outcomes for these 2 methods. Currently, no data comparing the outcomes of these 2 treatment options have been reported. A total of 62 patients were treated for Lisfranc fracture dislocations during a 6-year period. The inclusion criteria included ≥6 months of follow-up data available. Each fracture was classified using the Hardcastle classification system. Each fracture was also allocated into 1 of 4 groups: transarticular screw fixation, dorsal plating, a combination of plate and screw fixation, and nonoperative management. The outcome measures included the Kellgren-Lawrence grading of osteoarthritis and the Wilppula classification of anatomic reduction. In terms of results, radiologic osteoarthritis is not associated with the type of injury according to the Hardcastle classification nor with having an open or closed fracture. The Hardcastle classification is not associated with the type of fixation used. Fractures fixed with a combination of plates and screws had a 3.01 (95% confidence interval 1.036 to 8.74) increased risk of having stage 3 or 4 radiologic osteoarthritis compared with being fixed solely with bridging plates (p = .009). Multivariate analysis revealed that this increased risk of osteoarthritis was dependent on the quality of reduction, with good reductions having a 18.2 (95% confidence interval 15.9 to 21.8) times decreased risk of severe osteoarthritis compared with fair or poor reductions, independent of the type of fixation used (p < .0001). No radiologic benefits were found when comparing plate or screw fixation for Lisfranc fracture dislocations (although screw fixation might be associated with a less planus foot and fewer complications). Instead, a good anatomic reduction was the only predictor of the radiologic outcome, and the Hardcastle classification of fractures did not predict the surgery type or radiologic outcome. Finally, treatment with combination plates and screws resulted in worse radiologic outcomes, possibly owing to more complex fracture patterns.

Summary Background Probiotics may reduce necrotising enterocolitis and late-onset sepsis after preterm birth. However, there has been concern about the rigour and generalisability of some trials and there is no agreement about whether or not they should be used routinely. We aimed to test the effectiveness of the probiotic Bifidobacterium breve BBG-001 to reduce necrotising enterocolitis, late-onset sepsis, and death in preterm infants. Methods In this multicentre, randomised controlled phase 3 study (the PiPS trial), we recruited infants born between 23 and 30 weeks' gestational age within 48 h of birth from 24 hospitals in southeast England. Infants were randomly assigned (1:1) to probiotic or placebo via a minimisation algorithm randomisation programme. The probiotic intervention was B breve BBG-001 suspended in dilute elemental infant formula given enterally in a daily dose of 8·2 to 9·2 log 10 CFU; the placebo was dilute infant formula alone. Clinicians and families were masked to allocation. The primary outcomes were necrotising enterocolitis (Bell stage 2 or 3), blood culture positive sepsis more than 72 h after birth; and death before discharge from hospital. All primary analyses were by intention to treat. This trial is registered with ISRCTN, number 05511098 and EudraCT, number 2006-003445-17. Findings Between July 1, 2010, and July 31, 2013, 1315 infants were recruited; of whom 654 were allocated to probiotic and 661 to placebo. Five infants had consent withdrawn after randomisation, thus 650 were analysed in the probiotic group and 660 in the placebo group. Rates of the primary outcomes did not differ significantly between the probiotic and placebo groups. 61 infants (9%) in the probiotic group had necrotising enterocolitis compared with 66 (10%) in the placebo group (adjusted risk ratio 0·93 (95% CI 0·68–1·27); 73 (11%) infants in the probiotics group had sepsis compared with 77 (12%) in the placebo group (0·97 (0·73–1·29); and 54 (8%) deaths occurred before discharge home in the probiotic group compared with 56 (9%) in the placebo group (0·93 [0·67–1·30]). No probiotic-associated adverse events were reported. Interpretation There is no evidence of benefit for this intervention in this population; this result does not support the routine use of B breve BBG-001 for prevention of necrotising enterocolitis and late-onset sepis in very preterm infants. Funding UK National Institute for Health Research Health Technology Assessment programme.

Global spread of aggressive mycobacteria Many mycobacteria, in addition to those causing leprosy and tuberculosis, are capable of infecting humans. Some can be particularly dangerous in patients suffering from immunosuppression or chronic disease, such as cystic fibrosis (CF). Bryant et al. observed clusters of near-identical isolates of drug-resistant Mycobacterium abscessus in patients reporting to CF clinics. The similarity of the isolates suggests transmission between patients, rather than environmental acquisition. Although this bacterium is renowned for its environmental resilience, the mechanism for its long-distance transmission among the global CF patient community remains a puzzle. Science , this issue p. 751

Introduction. We describe a case of progressive disseminated histoplasmosis (PDH) and disseminated cytomegalovirus (CMV) with development of haemophagocytic lymphohistiocytosis in a 62-year-old man of Bangladeshi origin living in the UK. Case presentation. The patient had a background of ulcerative colitis for which he took prednisolone and azathioprine. He presented with fever, lethargy, cough, weight loss and skin redness, and was initially treated for bacterial cellulitis and investigated for underlying malignancy. He developed multiple progressive erythematous skin lesions, sepsis and colitis requiring management on intensive care. A skin biopsy showed yeasts in the dermis and sub-cutaneous fat, which were confirmed as Histoplasma capsulatum by PCR. Disseminated CMV with evidence of end organ gastrointestinal disease was also diagnosed. Despite anti-viral and anti-fungal treatment, the patient deteriorated with evidence of bone marrow suppression and a diagnosis of haemophagocytic lymphohistiocytosis was made. Conclusion. PDH is classically seen in patients with significant immunosuppression, e.g. those with human immunodeficiency virus (HIV) or on anti-TNF therapy; however, we present a case of reactivation of Histoplasma in a non-HIV patient. We consider the importance of contemplating reactivation of endemic mycoses and CMV in critically unwell and deteriorating patients.

Kisspeptin signalling is indispensable for fertility, stimulating gonadotropin-releasing hormone (GnRH) secretion and mediating gonadal steroid feedback on GnRH neurons. Moreover, kisspeptin neurons have been implicated in other non-reproductive neuroendocrine roles. Kisspeptin appears to also regulate growth hormone secretion but much of the data appear contradictory. We sought to clarify a potential role of kisspeptin in growth hormone (GH) regulation by examining the effect of kisspeptin antagonists on GH secretion in ewes under various physiological conditions. Our data show clear and robust increases in GH secretion following lateral ventricle or third ventricle infusion of kisspeptin antagonists p-234 and p-271 in either ovariectomized or anestrous ewes. Central infusion of kisspeptin-10 had no effect on GH secretion. To determine the level at which kisspeptin may influence GH secretion, we examined expression of the cognate kisspeptin receptor, GPR54, in pituitary cells and showed by immunocytochemistry that the majority of somatotropes express GPR54 while expression was largely negative in other pituitary cells. Overall, we have demonstrated that blocking kisspeptin signalling by antagonists stimulates GH secretion in ewes and that this is likely mediated by inhibiting endogenous kisspeptin activation of GPR54 expressed on somatotropes. The findings suggest that endogenous kisspeptin inhibits GH secretion through GPR54 expressed on somatotropes.