Multiple viral plaques with sebaceous differentiation associated with an unclassified papillomavirus type in a cat

CASE HISTORY AND CLINICAL FINDINGS A 15-year-old neutered male domestic short-haired cat was presented due to multiple 0.5-2 cm-diameter crusting plaques in the left preauricular region, over the bridge of nose, and in the right periocular region. The plaques did not appear to cause discomfort. HISTOPATHOLOGICAL FINDINGS Biopsy samples of four plaques were examined histologically. Three plaques consisted of well-demarcated foci of mild epidermal hyperplasia overlying markedly hyperplastic sebaceous glands. Approximately 60% of the hyperplastic cells contained a large cytoplasmic vacuole that ranged from being clear to containing prominent grey-blue fibrillar material. The fourth plaque was composed solely of epidermal hyperplasia, consistent with previous descriptions of feline viral plaques. MOLECULAR BIOLOGY Papillomavirus DNA was amplified from all four plaques using PCR. A single DNA sequence was amplified from the plaques with sebaceous differentiation. This sequence was identical to the FdPV-MY sequence previously suggested to be from a putative unclassified papillomavirus type. Felis catus papillomavirus type 2 sequences were amplified from the plaque typical of feline viral plaques. Immunohistochemistry to detect p16^CDKN2A protein (p16) showed marked immunostaining throughout the hyperplastic epidermis and adnexal structures within the plaques with sebaceous differentiation. DIAGNOSIS Multiple feline viral plaques with variable sebaceous differentiation. CLINICAL RELEVANCE Feline viral plaques with sebaceous differentiation have not been previously reported in cats. The presence of unique cell changes within these lesions, the detection of an unclassified papillomavirus type, and the p16 immunostaining within these plaques suggest that they may have been caused by the papillomavirus that contains the FdPV-MY sequence.

Results of the randomized phase IIB ARCTIC trial of low-dose rituximab in previously untreated CLL

ARCTIC was a multicenter, randomized-controlled, open, phase IIB non-inferiority trial in previously untreated chronic lymphocytic leukemia (CLL). Conventional frontline therapy in fit patients is fludarabine, cyclophosphamide and rituximab (FCR). The trial hypothesized that including mitoxantrone with low-dose rituximab (FCM-miniR) would be non-inferior to FCR. A total of 200 patients were recruited to assess the primary end point of complete remission (CR) rates according to IWCLL criteria. Secondary end points were progression-free survival (PFS), overall survival (OS), overall response rate, minimal residual disease (MRD) negativity, safety and cost-effectiveness. The trial closed following a pre-planned interim analysis. At final analysis, CR rates were 76 FCR vs 55% FCM-miniR (adjusted odds ratio: 0.37; 95% confidence interval: 0.19-0.73). MRD-negativity rates were 54 FCR vs 44% FCM-miniR. More participants experienced serious adverse reactions with FCM-miniR (49%) compared to FCR (41%). There are no significant differences between the treatment groups for PFS and OS. FCM-miniR is not expected to be cost-effective over a lifetime horizon. In summary, FCM-miniR is less well tolerated than FCR with an inferior response and MRD-negativity rate and increased toxicity, and will not be taken forward into a confirmatory trial. The trial demonstrated that oral FCR yields high response rates compared to historical series with intravenous chemotherapy.

Patient factors associated with non-attendance at colonoscopy after a positive screening faecal occult blood test

Background Screening participants with abnormal faecal occult blood test results who do not attend further testing are at high risk of colorectal cancer, yet little is known about their reasons for non-attendance. Methods We conducted a medical record review of 170 patients from two English Bowel Cancer Screening Programme centres who had abnormal guaiac faecal occult blood test screening tests between November 2011 and April 2013 but did not undergo colonoscopy. Using information from patient records, we coded and categorized reasons for non-attendance. Results Of the 170 patients, 82 were eligible for review, of whom 66 had at least one recorded reason for lack of colonoscopy follow-up. Reasons fell into seven main categories: (i) other commitments, (ii) unwillingness to have the test, (iii) a feeling that the faecal occult blood test result was a false positive, (iv) another health issue taking priority, (v) failing to complete bowel preparation, (vi) practical barriers (e.g. lack of transport), and (vii) having had or planning colonoscopy elsewhere. The most common single reasons were unwillingness to have a colonoscopy and being away. Conclusions We identify a range of apparent reasons for colonoscopy non-attendance after a positive faecal occult blood test screening. Education regarding the interpretation of guaiac faecal occult blood test findings, offer of alternative confirmatory test options, and flexibility in the timing or location of subsequent testing might decrease non-attendance of diagnostic testing following positive faecal occult blood test.

Improving uptake of flexible sigmoidoscopy screening: a randomized trial of nonparticipant reminders in the English Screening Programme

Background and study aims Uptake of flexible sigmoidoscopy screening in the English Bowel Scope Screening (BSS) Programme is low. The aim of this study was to test the impact of a nonparticipant reminder and theory-based leaflet to promote uptake among former nonresponders (previously did not confirm their appointment) and nonattenders (previously confirmed their appointment but did not attend). Patients and methods Eligible adults were men and women in London who had not attended a BSS appointment within 12 months of their invitation. Individuals were randomized (1:1:1) to receive no reminder (control), a 12-month reminder plus standard information booklet (TMR-SIB), or a 12-month reminder plus bespoke theory-based leaflet (TMR-TBL) designed to address barriers to screening. The primary outcome of the study was the proportion of individuals screened within each group 12 weeks after the delivery of the reminder. Results A total of 1383 men and women were randomized and analyzed as allocated (n = 461 per trial arm). Uptake was 0.2 % (n = 1), 10.4 % (n = 48), and 15.2 % (n = 70) in the control, TMR-SIB, and TMR-TBL groups, respectively. Individuals in the TMR-SIB and TMR-TBL groups were significantly more likely to attend screening than individuals in the control group (adjusted odds ratio [OR] 53.7, 95 % confidence interval [CI] 7.4 - 391.4, P < 0.001 and OR 89.0, 95 %CIs 12.3 - 645.4, P < 0.01, respectively). Individuals in the TMR-TBL group were also significantly more likely to attend screening than individuals in the TMR-SIB group (OR 1.7, 95 %CIs 1.1 - 2.5, P = 0.01). Across all groups, former nonattenders were more likely to participate in screening than former nonresponders (uptake was 14.2 % and 8.0 %, respectively; OR 2.5, 95 %CIs 1.4 - 4.4, P < 0.01). The adenoma detection rate among screened adults was 7.6 %, which is comparable to the rate in initial attenders. Conclusions Reminders targeting former nonparticipants can improve uptake and are effective for both former nonresponders and nonattenders. Theory-based information designed to target barriers to screening added significantly to this strategy.

The development of compulsive internet use and mental health: A four-year study of adolescence

Is compulsive Internet use (CIU) an antecedent to poor mental health, a consequence, or both? Study 1 used a longitudinal design to track the development of CIU and mental health in Grade 8 (N = 1030 males, 1038 females, Mage = 13.7), 9, 10, and 11. Study 2 extended Study 1 by examining the kinds of Internet behaviors most strongly associated with CIU within males and females. Structural equation modeling revealed that CIU predicted the development of poor mental health, whereas poor mental health did not predict CIU development. Latent growth analyses showed that both females and males increased in CIU and mental health problems across the high school years. Females had higher CIU and worse mental health than males, and tended to engage in more social forms of Internet use. We discuss future directions for CIU intervention research.

Aneurysmal SubArachnoid Hemorrhage-Red Blood Cell Transfusion And Outcome (SAHaRA): a pilot randomised controlled trial protocol

INTRODUCTION

Anaemia is common in aneurysmal subarachnoid haemorrhage (aSAH) and is a potential critical modifiable factor affecting secondary injury. Despite physiological evidence and management guidelines that support maintaining a higher haemoglobin level in patients with aSAH, current practice is one of a more restrictive approach to transfusion. The goal of this multicentre pilot trial is to determine the feasibility of successfully conducting a red blood cell (RBC) transfusion trial in adult patients with acute aSAH and anaemia (Hb ≤100 g/L), comparing a liberal transfusion strategy (Hb ≤100 g/L) with a restrictive strategy (Hb ≤80 g/L) on the combined rate of death and severe disability at 12 months.

METHODS

Design This is a multicentre open-label randomised controlled pilot trial at 5 academic tertiary care centres. Population We are targeting adult aSAH patients within 14 days of their initial bleed and with anaemia (Hb ≤110 g/L). Randomisation Central computer-generated randomisation, stratified by centre, will be undertaken from the host centre. Randomisation into 1 of the 2 treatment arms will occur when the haemoglobin levels of eligible patients fall to ≤100 g/L. Intervention Patients will be randomly assigned to either a liberal (threshold: Hb ≤100 g/L) or a restrictive transfusion strategy (threshold: Hb ≤80 g/L). Outcome Primary: Centre randomisation rate over the study period. Secondary: (1) transfusion threshold adherence; (2) study RBC transfusion protocol adherence; and (3) outcome assessment including vital status at hospital discharge, modified Rankin Score at 6 and 12 months and Functional Independence Measure and EuroQOL Quality of Life Scale scores at 12 months. Outcome measures will be reported in aggregate.

ETHICS AND DISSEMINATION

The study protocol has been approved by the host centre (OHSN-REB 20150433-01H). This study will determine the feasibility of conducting the large pragmatic RCT comparing 2 RBC transfusion strategies examining the effect of a liberal strategy on 12-month outcome following aSAH.

TRIAL REGISTRATION NUMBER

NCT02483351; Pre-results.

Assessment of interbreeding and introgression of farm genes into a small Scottish Atlantic salmon Salmo salar stock: ad hoc samples - ad hoc results?

An eclectic set of tissues and existing data, including purposely collected samples, spanning 1997-2006, was used in an ad hoc assessment of hybridization and introgression of farmed wild Atlantic salmon Salmo salar in the small Loch na Thull (LnT) catchment in north-west Scotland. The catchment is in an area of marine farm production and contains freshwater smolt rearing cages. The LnT S. salar stock was found to be genetically distinctive from stocks in neighbouring rivers and, despite regular reports of feral farm S. salar, there was no evidence of physical or genetic mixing. This cannot be completely ruled out, however, and low level mixing with other local wild stocks has been suggested. The LnT population appeared underpinned by relatively smaller effective number of breeders (N_eb ) and showed relatively low levels of genetic diversity, consistent with a small effective population size. Small sample sizes, an incomplete farm baseline and the use of non-diagnostic molecular markers, constrain the power of the analysis but the findings strongly support the LnT catchment having a genetically distinct wild S. salar population little affected by interbreeding with feral farm escapes.

Quantitative Raman Spectroscopy when the Signal-to-Noise is Below the Limit of Quantitation due to Fluorescence Interference: Advantages of a Moving Window Sequentially Shifted Excitation Approach

Raman spectroscopy is a useful analytical tool. However, its application is often limited because shot noise from fluorescence obscures the Raman signal. In such cases, quantitative analysis is not possible when the signal-to-noise ratio (SNR) drops below two. A method is described for performing quantitative Raman spectroscopy that not only removes fluorescence backgrounds, but also results in a significant improvement in the SNR. The Raman data is extracted using a moving window sequentially shifted excitation algorithm. To demonstrate the capabilities of the method, a binary mixture of two analytes at varying concentrations is quantified in the presence of a highly fluorescent dye. Linear calibration plots were constructed and validated for the binary model using individual Raman peaks with SNR ranging from 0.073-12.6; r(2) values are greater than 0.96 in all cases, with all but the weakest peaks yielding values greater than 0.997. The presented method demonstrates a universal and autonomous approach for the quantitative analysis of highly fluorescent samples via Raman spectroscopy. The lower limit on the SNR ratio for quantitative Raman analysis with the described method is 0.1. In order to assess the effectiveness of the presented method, the entire set of experiments was also processed using the more common shifted excitation Raman difference spectroscopy (SERDS) approach. The advantages of the proposed method over SERDS are demonstrated for both the detection limit and the SNR of the processed spectra.

The effect of shoulder pain on outcome of acute hemiplegia

The aim of this study was to decide whether shoulder pain in stroke is a marker of severity, or an independent predictor of poor outcome. The study was prospective observational in design from consecutive admissions. Acute medical and geriatric wards in three district hospitals provided the setting, and the subjects were 76 patients acutely admitted to hospital with a first stroke.

The main outcomes measured were length of stay in hospital, Barthel Index, Frenchay Arm Test, Motricity Index and discharge placement. After controlling for other indicators of stroke severity, shoulder pain on movement was the most important predictor of poor recovery of arm power and function, and an important contributor to length of stay in hospital. Urinary incontinence was the strongest indicator of length of stay and Barthel Index scores. Patients with subluxation and malalignment of the shoulder fared much more poorly than those with normal shoulder alignment. The results concluded that shoulder pain appears to influence outcome of stroke independent of severity. We recommend that this symptom receive careful attention.

At greatest risk: pre- and early adolescent Bahamian youth experiencing anal intercourse

Although anal intercourse carries great risk for HIV transmission, little research has focused on it among the general population, particularly pre- and early adolescents. This study describes the prevalence of anal and vaginal intercourse among Bahamian pre- and early adolescents and associations with other risk behaviours, family interactions and intrapersonal correlates. Data were from 1274 sixth-grade students aged 9–14 years who completed self-administered questionnaires at baseline of a larger school-based behavioural intervention study. Youth who reported having had anal intercourse engaged in significantly higher rates of several risk behaviours and were significantly more likely to engage in risk behaviours over the next six months, compared with youth with a history of vaginal intercourse only, who in turn were more likely than virgin adolescents. Youth indulging in anal intercourse also perceived significantly lower levels of parental monitoring. Multivariate analyses revealed that anal intercourse, vaginal intercourse, reduced parental monitoring, depression and perceived friend high-risk involvement were associated with both past involvement and future intention to engage in other risk behaviours. Anal intercourse poses a direct threat to the health of these children and is a flag for a constellation of other risks.

The success of microneedle-mediated vaccine delivery into skin

Microneedles (MNs) are designed to specifically target the outermost, skin barrier layer, the stratum corneum, creating transient pathways for minimally invasive transcutaneous delivery. It is reported that MNs can facilitate delivery without stimulating the pain receptors or damaging blood vessels that lie beneath, thus being perceived as painless and associated with reduced bleeding. This immunocompetence of the skin, coupled with its ease of access, makes this organ an attractive vaccination site. The purpose of this review was to collate primary scientific literature pertaining to MN-mediated in vivo vaccination programmes. A total of 62 original research articles are presented, compiling vaccination strategies in 6 different models (mouse, rat, guinea pig, rabbit, pig, macaque and human). Vaccines tested span a wide range of viral, bacterial and protozoan pathogens and includes 7 of the 13 vaccine-preventable diseases, as defined by the WHO. This review highlights the paucity of available clinical trial data. MN-delivered vaccines have demonstrated safety and immunogenicity in pre-clinical models and boast desirable attributes such as painless administration, thermostability, dose-sparing capacity and the potential for self-administration. These advantages should contribute to enhanced global vaccine access.

Use of a 12 months' self-referral reminder to facilitate uptake of bowel scope (flexible sigmoidoscopy) screening in previous non-responders: a London-based feasibility study

BACKGROUND

In March 2013, NHS England extended its national Bowel Cancer Screening Programme to include 'one-off' Flexible Sigmoidoscopy screening (NHS Bowel Scope Screening, BSS) for men and women aged 55. With less than one in two people currently taking up the screening test offer, there is a strong public health mandate to develop system-friendly interventions to increase uptake while the programme is rolling out. This study aimed to assess the feasibility of sending a reminder to previous BSS non-responders, 12 months after the initial invitation, with consideration for its potential impact on uptake.

METHOD

This study was conducted in the ethnically diverse London Boroughs of Brent and Harrow, where uptake is below the national average. Between September and November 2014, 160 previous non-responders were randomly selected to receive a reminder of the opportunity to self-refer 12 months after their initial invitation. The reminder included instructions on how to book an appointment, and provided options for the time and day of the appointment and the gender of the endoscopist performing the test. To address barriers to screening, the reminder was sent with a brief locally tailored information leaflet designed specifically for this study. Participants not responding within 4 weeks were sent a follow-up reminder, after which there was no further intervention. Self-referral rates were measured 8 weeks after the delivery of the follow-up reminder and accepted as final.

RESULTS

Of the 155 participants who received the 12 months' reminder (returned to sender, n=5), 30 (19.4%) self-referred for an appointment, of which 24 (15.5%) attended and were successfully screened. Attendance rates differed by gender, with significantly more women attending an appointment than men (20.7% vs 8.8%, respectively; OR=2.73, 95% CI=1.02-7.35, P=0.05), but not by area (Brent vs Harrow) or area-level deprivation. Of the 30 people who self-referred for an appointment, 27 (90%) indicated a preference for a same-sex practitioner, whereas three (10%) gave no preference. Preference for a same-sex practitioner was higher among women than men (χ(2)=7.78, P<0.05), with only 67% of men (six of nine) requesting a same-sex practitioner, compared with 100% of women (n=21).

CONCLUSIONS

Sending previous non-responders a 12 months' reminder letter with a brief information leaflet is a feasible and efficacious intervention, which merits further investigation in a randomised controlled trial.

An international study of the quality of national-level guidelines on driving with medical illness

BACKGROUND

Medical illnesses are associated with a modest increase in crash risk, although many individuals with acute or chronic conditions may remain safe to drive, or pose only temporary risks. Despite the extensive use of national guidelines about driving with medical illness, the quality of these guidelines has not been formally appraised.

AIM

To systematically evaluate the quality of selected national guidelines about driving with medical illness.

DESIGN

A literature search of bibliographic databases and Internet resources was conducted to identify the guidelines, each of which was formally appraised.

METHODS

Eighteen physicians or researchers from Canada, Australia, Ireland, USA and UK appraised nine national guidelines, applying the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

RESULTS

Relative strengths were found in AGREE II scores for the domains of scope and purpose, stakeholder involvement and clarity of presentation. However, all guidelines were given low ratings on rigour of development, applicability and documentation of editorial independence. Overall quality ratings ranged from 2.25 to 5.00 out of 7.00, with modifications recommended for 7 of the guidelines. Intra-class coefficients demonstrated fair to excellent appraiser agreement (0.57-0.79).

CONCLUSIONS

This study represents the first systematic evaluation of national-level guidelines for determining medical fitness to drive. There is substantive variability in the quality of these guidelines, and rigour of development was a relative weakness. There is a need for rigorous, empirically derived guidance for physicians and licensing authorities when assessing driving in the medically ill.

Frontotemporal dementia caused by CHMP2B mutation is characterised by neuronal lysosomal storage pathology

Mutations in the charged multivesicular body protein 2B (CHMP2B) cause frontotemporal dementia (FTD). We report that mice which express FTD-causative mutant CHMP2B at physiological levels develop a novel lysosomal storage pathology characterised by large neuronal autofluorescent aggregates. The aggregates are an early and progressive pathology that occur at 3 months of age and increase in both size and number over time. These autofluorescent aggregates are not observed in mice expressing wild-type CHMP2B, or in non-transgenic controls, indicating that they are a specific pathology caused by mutant CHMP2B. Ultrastructural analysis and immuno- gold labelling confirmed that they are derived from the endolysosomal system. Consistent with these findings, CHMP2B mutation patient brains contain morphologically similar autofluorescent aggregates. These aggregates occur significantly more frequently in human CHMP2B mutation brain than in neurodegenerative disease or age-matched control brains. These data suggest that lysosomal storage pathology is the major neuronal pathology in FTD caused by CHMP2B mutation. Recent evidence suggests that two other genes associated with FTD, GRN and TMEM106B are important for lysosomal function. Our identification of lysosomal storage pathology in FTD caused by CHMP2B mutation now provides evidence that endolysosomal dysfunction is a major degenerative pathway in FTD.