A national survey investigating the impact of the COVID-19 pandemic on core and higher breast radiology training in the UK

AIM

To investigate the impact of the COVID-19 pandemic on core and higher breast radiology training in the UK from the perspective of trainees and new consultants.

MATERIALS AND METHODS

A survey comprising 25 questions was distributed to UK radiology trainees via the regional Junior Radiologists Forum representatives under the auspices of the British Society of Breast Radiology (BSBR).

RESULTS

Sixty-nine eligible responses were received representing all UK training regions. Fifty-five per cent of respondents completing either a core or higher breast rotation felt that the pandemic had a negative effect on their breast training. There was an overall reduction in exposure to the key breast imaging methods when rotations took place during the pandemic. Completing a core breast rotation during the pandemic was less likely to attract trainees to higher breast training. Three out of four breast radiology consultants in their first year after receiving their Certificate of Completion of Training (CCT) felt the pandemic reduced their preparedness for becoming consultants. Positive outcomes included the increased use of online educational resources and remote multidisciplinary meetings.

CONCLUSIONS

As well as having a negative impact on breast radiology training overall, the pandemic has had a detrimental effect on attracting trainees to breast radiology as a future career. It is of key importance that trainees have a positive core breast rotation as this experience appears central to many trainees' decisions to pursue higher breast training. Increased use of online learning resources has also been positively received and is a valuable approach to learning that can be maintained in the longer term.

Operationalising coastal resilience to flood and erosion hazard: A demonstration for England

Resilience is widely seen as an important attribute of coastal systems and, as a concept, is increasingly prominent in policy documents. However, there are conflicting ideas on what constitutes resilience and its operationalisation as an overarching principle of coastal management remains limited. In this paper, we show how resilience to coastal flood and erosion hazard could be measured and applied within policy processes, using England as a case study. We define resilience pragmatically, integrating what is presently a disparate set of policy objectives for coastal areas. Our definition uses the concepts of resistance, recovery and adaptation, to consider how the economic, social and environmental dimensions of coastal systems respond to change. We develop a set of composite indicators for each dimension, grounded empirically with reference to national geospatial datasets. A prototype Coastal Resilience Model (CRM) has been developed, which combines the dimensions and generates a quantitative resilience index. We apply it to England's coastal hazard zone, capturing a range of different stakeholder perspectives using relative indicator weightings. The illustrative results demonstrate the practicality of formalising and quantifying resilience. To re-focus national policy around the stated desire of enhancing resilience to coastal flooding and erosion would require firm commitment from government to monitor progress towards resilience, requiring extension of the present risk-based approach, and a consensus methodology in which multiple (and sometimes conflicting) stakeholder values are explicitly considered. Such a transition may also challenge existing governance arrangements at national and local levels, requiring incentives for coastal managers to engage with and apply this new approach, more departmental integration and inter-agency cooperation. The proposed Coastal Resilience Model, with the tools to support planning and measure progress, has the potential to help enable this transition.

Blood-feeding patterns of native mosquitoes and insights into their potential role as pathogen vectors in the Thames estuary region of the United Kingdom

BACKGROUND

The range of vertebrate hosts on which species of mosquito blood-feed is an important parameter for identifying potential vectors and in assessing the risk of incursion and establishment of vector-borne pathogens. In the United Kingdom, studies of mosquito host range have collected relatively few specimens and used techniques that could only broadly identify host species. This study conducted intensive collection and analysis of mosquitoes from a grazing marsh environment in southeast England. This site provides extensive wetland habitat for resident and migratory birds and has abundant human nuisance biting mosquitoes. The aim was to identify the blood-feeding patterns of mosquito species present at the site which could contribute to the transmission of pathogens.

METHODS

Twice-weekly collections of mosquitoes were made from Elmley Nature Reserve, Kent, between June and October 2014. Mosquitoes were collected using resting boxes, by aspiration from man-made structures and using a Mosquito Magnet Pro baited with 1-octen-3-ol. Blood-fed specimens were classified according to the degree of blood meal digestion using the Sella scale and vertebrate origin determined using sequencing of a fragment of the mitochondrial cytochrome C oxidase subunit I gene. Mosquitoes that were morphologically cryptic were identified to species level using multiplex PCR and sequencing methods.

RESULTS

A total of 20,666 mosquitoes of 11 species were collected, and 2,159 (10.4%) were blood-fed (Sella scale II-VI); of these 1,341 blood-fed specimens were selected for blood meal analysis. Vertebrate origin was successfully identified in 964 specimens (72%). Collections of blood-fed individuals were dominated by Anopheles maculipennis complex (73.5%), Culiseta annulata (21.2%) and Culex pipiens form pipiens (10.4%). Nineteen vertebrate hosts comprising five mammals and 14 birds were identified as hosts for mosquitoes, including two migratory bird species. Feeding on birds by Culex modestus and Anopheles atroparvus populations in England was demonstrated.

CONCLUSIONS

This study expands the vertebrate host range of mosquitoes in the Thames estuary region of the UK. Feeding on both resident and migratory bird species by potential arbovirus vectors including Cx. pipiens f. pipiens and Cx. modestus indicates the potential for enzootic transmission of an introduced arbovirus between migratory and local bird species by native mosquito species.

Diagnosis and misdiagnosis of adult neuronal ceroid lipofuscinosis (Kufs disease)

OBJECTIVE

To critically re-evaluate cases diagnosed as adult neuronal ceroid lipofuscinosis (ANCL) in order to aid clinicopathologic diagnosis as a route to further gene discovery.

METHODS

Through establishment of an international consortium we pooled 47 unsolved cases regarded by referring centers as ANCL. Clinical and neuropathologic experts within the Consortium established diagnostic criteria for ANCL based on the literature to assess each case. A panel of 3 neuropathologists independently reviewed source pathologic data. Cases were given a final clinicopathologic classification of definite ANCL, probable ANCL, possible ANCL, or not ANCL.

RESULTS

Of the 47 cases, only 16 fulfilled the Consortium's criteria of ANCL (5 definite, 2 probable, 9 possible). Definitive alternate diagnoses were made in 10, including Huntington disease, early-onset Alzheimer disease, Niemann-Pick disease, neuroserpinopathy, prion disease, and neurodegeneration with brain iron accumulation. Six cases had features suggesting an alternate diagnosis, but no specific condition was identified; in 15, the data were inadequate for classification. Misinterpretation of normal lipofuscin as abnormal storage material was the commonest cause of misdiagnosis.

CONCLUSIONS

Diagnosis of ANCL remains challenging; expert pathologic analysis and recent molecular genetic advances revealed misdiagnoses in >1/3 of cases. We now have a refined group of cases that will facilitate identification of new causative genes.

Morphometric discrimination of two sympatric sibling species in the Palaearctic region, Culicoides obsoletus Meigen and C. scoticus Downes & Kettle (Diptera: Ceratopogonidae), vectors of bluetongue and Schmallenberg viruses

Background

Some Palaearctic biting midge species (subgenus Avaritia) have been implicated as vectors of bluetongue virus in northern Europe. Separation of two species (C. obsoletus and C. scoticus) is considered difficult morphologically and, often, these female specimens are grouped in entomological studies. However, species-specific identification is desirable to understand their life history characteristics, assess their roles in disease transmission or measure their abundance during arboviral outbreaks. This study aims to investigate whether morphometric identification techniques can be applied to female C. obsoletus and C. scoticus individuals trapped at different geographical regions and time periods during the vector season.

Methods

C. obsoletus and C. scoticus were collected using light-suction traps from the UK, France and Spain, with two geographical locations sampled per country. A total of 759 C. obsoletus/C. scoticus individuals were identified using a molecular assay based on the cytochrome c oxidase subunit I gene. Fifteen morphometric measurements were taken from the head, wings and abdomen of slide-mounted specimens, and ratios calculated between these measurements. Multivariate analyses explored whether a combination of morphometric variables could lead to accurate species identification. Finally, Culicoides spp. collected in France at the start, middle and end of the adult vector season were compared, to determine whether seasonal variation exists in any of the morphometric measurements.

Results

The principal component analyses revealed that abdominal characteristics: length and width of the smaller and larger spermathecae, and the length of the chitinous plates and width between them, are the most reliable morphometric characteristics to differentiate between the species. Seasonal variation in the size of each species was observed for head and wing measurements, but not abdominal measurements. Geographical variation in the size of Culicoides spp. was also observed and is likely to be related to temperature at the trapping sites, with smaller individuals trapped at more southern latitudes.

Conclusions

Our results suggest that female C. obsoletus and C. scoticus individuals can be separated under a stereomicroscope using abdominal measurements. Although we show the length and width of the spermathecae can be used to differentiate between the species, this can be time-consuming, so we recommend undertaking this using standardized subsampling of catches.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-016-1520-7) contains supplementary material, which is available to authorized users.

Wearing a Wetsuit Alters Upper Extremity Motion during Simulated Surfboard Paddling

Surfers often wear wetsuits while paddling in the ocean. This neoprene covering may be beneficial to upper extremity movement by helping to improve proprioceptive acuity, or it may be detrimental by providing increased resistance. The purpose of this study was to evaluate the effects of wearing a wetsuit on muscle activation, upper extremity motion, heart rate, and oxygen consumption during simulated surfboard paddling in the laboratory. Twelve male, recreational surfers performed two paddling trials at a constant workload on a swim bench ergometer both with and without a wetsuit. Kinematic data and EMG were acquired from the right arm via motion capture, and oxygen consumption and heart rate were recorded with a metabolic cart and heart rate monitor. Wearing a wetsuit had no significant effect on oxygen consumption or heart rate. A significant increase in EMG activation was observed for the middle deltoid but not for any of the other shoulder muscle evaluated. Finally, approximate entropy and estimates of the maximum Lyapunov exponent increased significantly for vertical trajectory of the right wrist (i.e. stroke height) when a wetsuit was worn. These results suggest that a 2mm wetsuit has little effect on the energy cost of paddling at lower workloads but does affect arm motion. These changes may be the result of enhanced proprioceptive acuity due to mechanical compression from the wetsuit.

Vector competence of Culicoides for arboviruses: three major periods of research, their influence on current studies and future directions

The spectacular and unprecedented outbreaks of bluetongue virus (BTV) that have occurred in Europe since 1998 have led to increased interest in those factors that determine competence of Culicoides biting midges (Diptera: Ceratopogonidae) for arboviruses. In this review the authors critically examine three major periods of research into the biological transmission by Culicoides of two economically important arboviruses ofthefamily Reoviridae: African horse sicknessvirus (AHSV) and BTV. First they examine early studies, largely conducted in southern Africa, that played a key role in initially implicating Culicoides as agents of AHSV and BTV transmission. Then they examine advances in understanding made following the establishment of colonies of the BTV vector species Culicoides sonorensis, which have largely shaped our current understanding of BTV and AHSV transmission. They then consider attempts in recent years to implicate vectors of BTV in the European Union during what has become the most economically damaging series of outbreaks in recorded history. In some cases the origin of these outbreaks was uncertain and unexpected, particularly in northern Europe, where BTV had not previously occurred. Limitations imposed on studies of vector competence by the biology of Culicoides are then discussed, along with advances in the technologies now available and the logistics of working upon agents requiring biosecure containment outside their endemic range. Finally, the authors suggest areas that have either been poorly addressed to date or entirely ignored and ways in which studies could be conducted to provide standardised data for comparison worldwide.

Bionomics of temperate and tropical Culicoides midges: knowledge gaps and consequences for transmission of Culicoides-borne viruses

Culicoides midges are abundant hematophagous flies that vector arboviruses of veterinary and medical importance. Dramatic changes in the epidemiology of Culicoides-borne arboviruses have occurred since 1998, including the emergence of exotic viruses in northern temperate regions, increases in global disease incidence, and enhanced virus diversity in tropical zones. Drivers may include changes in climate, land use, trade, and animal husbandry. New Culicoides species and new wild reservoir hosts have been implicated in transmission, highlighting the dynamic nature of pathogen-vector-host interactions. Focusing on potential vector species worldwide and key elements of vectorial capacity, we review the sensitivity of Culicoides life cycles to abiotic and biotic factors. We consider implications for designing control measures and understanding impacts of environmental change in different ecological contexts. Critical geographical, biological, and taxonomic knowledge gaps are prioritized. Recent developments in genomics and mathematical modeling may enhance ecological understanding of these complex arbovirus systems.

Simulation of Brain Death from Fulminant De-efferentation

Background:

Guillain-BarrÈ syndrome (GBS) classically presents with a subacutely evolving areflexic paralysis, with typical laboratory findings of elevated cerebrospinal fluid protein and abnormal nerve conduction studies. There is now an increasing recognition of GBS variants that differ in clinical presentation, prognosis, electrophysiology and presumed pathogenesis. Fulminant cases of GBS have been reported in which a rapid deterioration evolves to a clinical state resembling ìbrain deathî.

Methods:

A retrospective analysis of two such cases of fulminant neuropathy are described, that includes the clinical course, electrophysiology and neuropathology where available.

Results:

We describe two patients that presented with a rapid course of neurological deterioration, lapsing into what resembled a ìclinically brain-deadî state that was subsequently ascribed to a fulminant polyneuropathy. Investigations (electrophysiological, pathological) and the clinical course suggested an axonal neuropathy.

Conclusion:

A fulminant neuropathy can result in a clinical state resembling ìbrain deathî through diffuse de-efferentation. Although generally attributed to aggressive demyelination with secondary axonal degeneration, a primary axonopathy can also lead to a similar clinical presentation.

"We have to try and have this child before it is too late": missed opportunities in client-provider communication on reproductive intentions of people living with HIV

Men and women living with HIV with access to ARVs are living longer, healthier lives that can and often do include bearing children. Children occupy a key space in men and women's personal and social lives and often play a fundamental role in maintaining these relationships, irrespective of illness concerns. Couples living with HIV need to balance prevention needs and ill-health while trying to maintain healthy relationships. Health-care providers serving the reproductive needs of HIV-affected couples need to consider the social and relational factors shaping reproductive decisions associated with periconception risk behaviors. This paper based on qualitative research at three hospital sites in eThekwini District, South Africa, investigates the childbearing intentions and needs of people living with HIV (PLHIV), and the attitudes and experiences of health-care providers serving the reproductive needs of PLHIV, and client and provider views and knowledge of safer conception. This research revealed that personal, social, and relationship dynamics shape the reproductive decisions of PLHIV, and "unplanned" pregnancies are not always unintended. Additionally, conception desires are not driven by the number of living children; rather clients are motivated by whether or not they have had any children with their current partner/spouse. Providers should consider the relationship status of clients in discussions about childbearing desires and intentions. Although many providers recognize the complex social realities shaping their clients' reproductive decisions, they have outdated information on serving their reproductive needs. Appropriate training to enable providers to better understand the relationship and social realities surrounding their clients' childbearing intentions is required and should be used as a platform for couples to work together with providers toward safer conception. The adoption of a more participatory approach should be employed to equalize client-provider power dynamics and to ensure clients are more involved in decision-making about reproduction and conception.

Phenotypic differentiation and phylogenetic signal of wing shape in western European biting midges, Culicoides spp., of the subgenus Avaritia

In the past decade biting midges of the subgenus Avaritia (Diptera: Ceratopogonidae) have been popular subjects of applied entomological studies in Europe owing to their implication as biological vectors in outbreaks of bluetongue and Schmallenberg viruses. This study uses a combination of cytochrome oxidase subunit I barcode sequencing and geometric morphometric analyses to investigate wing shape as a means to infer species identification within this subgenus. In addition the congruence of morphological data with different phylogenetic hypotheses is tested. Five different species of the subgenus Avaritia were considered in the study (C. obsoletus (Meigen); C. scoticus Kettle and Lawson; C. chiopterus (Meigen); C. dewulfi Goetghebuer and C. imicola (Kieffer)). The study demonstrated that over 90% of individuals could be separated correctly into species by their wing shape and that patterns of morphological differentiation derived from the geometric morphometric analyses were congruent with phylogenies generated from sequencing data. Morphological data produced are congruent with monophyly of the subgenus Avaritia and the exclusion of C. dewulfi from the group containing C. obsoletus, C. scoticus and C. chiopterus. The implications of these results and their importance in a wider context of integrating multiple data types to interpret both phylogeny and species characterization is discussed.

Homografts and extra-anatomical reconstructions for infected vascular grafts

Managing graft infections is a challenge in vascular surgery. The incidence of vascular graft infections varies between 2% and 6%. The number of patients treated by means of implantation of artificial prostheses is constantly growing. The treatment of vascular graft infections remains controversial. This article discusses in-situ repair and the role of extra-anatomic routes. Homografts present the lowest rate of reinfection with acceptable rates of degradation and aneurysm formation. Silvergrafts and synthetic grafts coated with antimicrobials show similar early and late mortality rates, but higher reinfection rates. The outcome extra-anatomic bypass surgery seems to be improved in actual series compared with historical results but their disadvantages (limited patency, higher rate of amputations as well as high rates of reintervention combined with higher early mortality) are obvious.

Larval development and emergence sites of farm-associated Culicoides in the United Kingdom

Culicoides biting midges (Diptera: Ceratopogonidae) are the biological vectors of internationally important arboviruses of livestock including bluetongue virus (BTV). Information on the habitats used by Culicoides for larval development is valuable for establishing targeted vector control strategies and for improving local scale models of vector abundance. This study combines emergence trap collections of adult Culicoides identified using molecular markers and physiochemical measurements of habitats to investigate larval development sites of Palaearctic Culicoides in South East England. The known range of larval habitats for several Culicoides species is extended and the potential BTV vector species C. obsoletus and C. scoticus are confirmed to co-occur in many larval habitats. The presence of emerging C. obsoletus was favoured by increasing substrate moisture level [odds ratio (OR) 6.94 (2.30; 20.90)] and substrate pH [OR 4.80 (1.66; 13.90)] [bias-corrected Dxy : 0.68; area under the curve (AUC): 0.86] rather than any particular larval habitat type, as expected for a species with relatively wide larval habitat preference. Of the newly emerged sub-genus Avaritia individuals collected, 23% were observed to have a degree of abdominal pigmentation commonly inferred to indicate parity. If consistent across species and locations, this observation represents a potential source of error for age structure analyses of Culicoides populations.

Cathepsin F mutations cause Type B Kufs disease, an adult-onset neuronal ceroid lipofuscinosis

Kufs disease, an adult-onset neuronal ceroid lipofuscinosis, is challenging to diagnose and genetically heterogeneous. Mutations in CLN6 were recently identified in recessive Kufs disease presenting as progressive myoclonus epilepsy (Type A), whereas the molecular basis of cases presenting with dementia and motor features (Type B) is unknown. We performed genome-wide linkage mapping of two families with recessive Type B Kufs disease and identified a single region on chromosome 11 to which both families showed linkage. Exome sequencing of five samples from the two families identified homozygous and compound heterozygous missense mutations in CTSF within this linkage region. We subsequently sequenced CTSF in 22 unrelated individuals with suspected recessive Kufs disease, and identified an additional patient with compound heterozygous mutations. CTSF encodes cathepsin F, a lysosomal cysteine protease, dysfunction of which is a highly plausible candidate mechanism for a storage disorder like ceroid lipofuscinosis. In silico modeling suggested the missense mutations would alter protein structure and function. Moreover, re-examination of a previously published mouse knockout of Ctsf shows that it recapitulates the light and electron-microscopic pathological features of Kufs disease. Although CTSF mutations account for a minority of cases of type B Kufs, CTSF screening should be considered in cases with early-onset dementia and may avoid the need for invasive biopsies.

Development of Leishmania parasites in Culicoides nubeculosus (Diptera: Ceratopogonidae) and implications for screening vector competence

Biting midges of the genus Forcipomyia (Diptera: Ceratopogonidae) have recently been implicated as vectors of kinetoplastid parasites in the Leishmania enrietti complex. This study assesses susceptibility of one of the few successfully colonized Ceratopogonidae, Culicoides nubeculosus Meigen, to infection with Leishmania parasites infecting humans. While Leishmania infantum initially developed in the midgut of C. nubeculosus until 2 d postfeeding, parasite populations on day 3 were considerably reduced. Despite this, a polymerase chain reaction-based assay continued to indicate presence of L. infantum for up to 7 d after the bloodmeal. These findings are discussed within the wider context of implicating arthropods as vectors of Leishmania and it is suggested that conventional polymerase chain reaction use in vector-competence studies should be accompanied by direct microscopical observations.

Strikingly different clinicopathological phenotypes determined by progranulin-mutation dosage

We performed hypothesis-free linkage analysis and exome sequencing in a family with two siblings who had neuronal ceroid lipofuscinosis (NCL). Two linkage peaks with maximum LOD scores of 3.07 and 2.97 were found on chromosomes 7 and 17, respectively. Unexpectedly, we found these siblings to be homozygous for a c.813_816del (p.Thr272Serfs∗10) mutation in the progranulin gene (GRN, granulin precursor) in the latter peak. Heterozygous mutations in GRN are a major cause of frontotemporal lobar degeneration with TDP-43 inclusions (FTLD-TDP), the second most common early-onset dementia. Reexamination of progranulin-deficient mice revealed rectilinear profiles typical of NCL. The age-at-onset and neuropathology of FTLD-TDP and NCL are markedly different. Our findings reveal an unanticipated link between a rare and a common neurological disorder and illustrate pleiotropic effects of a mutation in the heterozygous or homozygous states.

Investigating incursions of bluetongue virus using a model of long-distance Culicoides biting midge dispersal

Bluetongue virus (BTV) is an economically important pathogen of ruminants that is the aetiological agent of the haemorrhagic disease bluetongue. Bluetongue virus is biologically transmitted by Culicoides biting midges (Diptera: Ceratopogonidae), and long-range dispersal of infected vector species contributes substantially to the rapid spread of the virus. The range of semi-passive flights of infected Culicoides on prevailing winds has been inferred to reach several hundred kilometres in a single night over water bodies. In this study, an atmospheric dispersion model was parameterized to simulate Culicoides flight activity based on dedicated entomological data sets collected in the UK. Five outbreaks of BTV in Europe were used to evaluate the model for use as an early warning tool and for retrospective analyses of BTV incursions. In each case, the generated predictions were consistent with epidemiological observations confirming its reliability for use in disease outbreak management. Furthermore, the model aided policy makers to predict, contain and eradicate BTV outbreaks in the UK during 2007 and 2008.

Impacts of climate, host and landscape factors on Culicoides species in Scotland

Culicoides biting midges (Diptera: Ceratopogonidae) vector a wide variety of internationally important arboviral pathogens of livestock and represent a widespread biting nuisance. This study investigated the influence of landscape, host and remotely-sensed climate factors on local abundance of livestock-associated species in Scotland, within a hierarchical generalized linear model framework. The Culicoides obsoletus group and the Culicoides pulicaris group accounted for 56% and 41%, respectively, of adult females trapped. Culicoides impunctatus Goetghebuer and C. pulicaris s.s. Linnaeus were the most abundant and widespread species in the C. pulicaris group (accounting for 29% and 10%, respectively, of females trapped). Abundance models performed well for C. impunctatus, Culicoides deltus Edwards and Culicoides punctatus Meigen (adjusted R(2) : 0.59-0.70), but not for C. pulicaris s.s. (adjusted R(2) : 0.36) and the C. obsoletus group (adjusted R(2) : 0.08). Local-scale abundance patterns were best explained by models combining host, landscape and climate factors. The abundance of C. impunctatus was negatively associated with cattle density, but positively associated with pasture cover, consistent with this species' preference in the larval stage for lightly grazed, wet rush pasture. Predicted abundances of this species varied widely among farms even over short distances (less than a few km). Modelling approaches that may facilitate the more accurate prediction of local abundance patterns for a wider range of Culicoides species are discussed.

A novel type of familial proximal axonal dystrophy: three cases and a review of the axonal dystrophies

Three related infants of Roma ancestry, two of them siblings, showed hypotonia, predominantly axial, from birth, difficulty swallowing, myoclonic seizures, and respiratory difficulty. Dysmorphic features, principally micrognathia were present. EEGs showed focal epileptiform abnormalities. All three died in their 5th month from respiratory insufficiency complicated by pneumonia. Autopsy showed small brains without malformation. Microscopy revealed numerous axonal spheroids involving particularly the brain stem and spinal cord, with especial prominence in the middle cerebellar peduncle, the anterior part of the thalamic reticular nuclei, and the anterior horns and columns of the spinal cord. Spheroids that appeared to be on axons of lower motor neurons were especially large. No spheroids were seen in peripheral nerves; electron microscopy did not show spheroids in skin. By electron microscopy spheroids contained neurofilaments, sparse mitochondria, and electron dense granules. The material did not allow identification of microtubules. Closely packed vesicles excluded neurofilamanets from the center of many spheroids, especially in the middle cerebellar peduncle. Sprouting of axons from the surface of many spheroids was seen. This disease is distinct from the well described type of infantile neuroaxonal dystrophy (Seitelberger's disease) in view of the distribution of spheroids, presence of spheroids on proximal rather than distal parts of axons, sparing of the peripheral nerves, lack of staining for synuclein, presence of sprouting, and lack of membranous profiles in the spheroids. A review of reported types of axonal dystrophy has not shown identical cases.

Current prescription of prophylactic factor infusions and perceived adherence for children and adolescents with haemophilia: a survey of haemophilia healthcare professionals in the United States

The primary goal of prophylaxis in patients with severe haemophilia is to convert the phenotype from severe to moderate and to prevent the development of chronic arthropathy. Prior studies have demonstrated that prophylaxis decreases episodes of joint bleeds and chronic arthropathy. Effectiveness depends on prescription of prophylaxis and adherence to the prescribed regimen. The aim of this study was to determine if prescription of prophylaxis for children with haemophilia and perceptions of adherence to prophylaxis have changed since publication of the Joint Outcome Study (JOS). A questionnaire was sent, in electronic and written formats, to health professionals who provide care to children with haemophilia at US haemophilia treatment centres (HTCs). The response rate was 56 of 128 (44%) of the targeted HTCs. There were a few missing data and denominators are provided. All responses agreed with the results of the JOS and 30/55 (55%) reported the JOS increased their prescription of prophylaxis. Nineteen of 56 (34%) physicians or HTC staff reported that they had not prescribed prophylaxis within the last year due to concerns about adherence, and 19/56 (34%) reported they had stopped prophylaxis due to concerns about adherence within the last year. Predicted adherence decreased with increasing age. Prescription of prophylaxis appears to be increasing since publication of the JOS. Strategies to improve adherence may increase the likelihood of physician prescription of prophylaxis and make prophylaxis easier to implement for individual patients, thereby improving the clinical outcome of children and adults with haemophilia.

Collection of Culicoides (Diptera: Ceratopogonidae) using CO2 and enantiomers of 1-octen-3-ol in the United Kingdom

The host kairomones carbon dioxide (CO2) and 1-octen-3-ol elicit a host seeking response in a wide range of haematophagous Diptera. This study investigates the response of Culicoides biting midges (Diptera: Ceratopogonidae) to these cues using field-based experiments at two sites in the United Kingdom with very different species complements. Traps used for surveillance (miniature CDC model 512) and control (Mosquito Magnet Pro) were modified to release ratios of (R)- and (S)-1-octen-3-ol enantiomers in combination with CO2 and, in the case of the latter trap type, a thermal cue. Abundance and species diversity were then compared between these treatments and against collections made using a trap with a CO2 lure only, in a Latin square design. In both habitats, results demonstrated that semiochemical lures containing a high proportion of the (R)-enantiomer consistently attracted a greater abundance of host-seeking Culicoides females than any other treatment. Culicoides collected using an optimal stimulus of 500 ml/min CO2 combined with 4.1 mg/h (R)-1-octen-3-ol were then compared with those collected on sheep through the use of a drop trap. While preliminary in nature, this trial indicated Culicoides species complements are similar between collections made using the drop trap in comparison to the semiochemical-baited CDC trap, and that there are advantages in using (R)-1-octen-3-ol.

Evaluation of matrix-assisted laser desorption/ionization time of flight mass spectrometry for characterization of Culicoides nubeculosus biting midges

Matrix-assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF MS) has shown promise in species identification of insect species. We evaluated its potential to consistently characterize laboratory-reared biting midges of the species Culicoides nubeculosus (Meigen) (Diptera: Ceratopogonidae). Twenty-one reproducible potential biomarker masses for C. nubeculosus were identified under different experimental treatments. These treatments included the homogenization of insects in either water or known concentrations of formic acid. The biomarker masses were present independent of age, gender and different periods of storage of individuals in 70% ethanol (a standard preservation method). It was found that the presence of blood in females reduced the intensity of the MALDI-TOF pattern, necessitating the removal of the abdomen before analysis. The protein profiles of a related non-biting midge, Forcipomyia sp. (Diptera: Ceratopogonidae), and of Aedes japonicus japonicus (Theobald) (Diptera: Culicidae) mosquitoes were also examined and were distinctly different. These findings provide preliminary data to optimize future studies in differentiation of species within the Culicoides genus using MALDI-TOF MS which is a rapid, simple, reliable and cost-effective technique.

Laboratory and field-based tests of deltamethrin insecticides against adult Culicoides biting midges

Bluetongue virus (BTV) is an economically important arbovirus of ruminants transmitted by Culicoides biting midges. Vector control using residual spraying or application to livestock is recommended by many authorities to reduce BTV transmission; however, the impact of these measures in terms of both inflicting mortality on Culicoides and subsequently upon BTV transmission is unclear. This study consisted of a standardized World Health Organization laboratory assay to determine the susceptibility of European Culicoides species to deltamethrin and a field trial based upon allowing individuals of a laboratory strain of Culicoides nubeculosus Meigen to feed upon sheep treated with Butox 7.5 pour-on (a deltamethrin-based topical formulation). Susceptibility in the laboratory trial was higher in colony C. nubeculosus (24-h LC90 = 0.00106%), than in field populations of Culicoides obsoletus Meigen (24-h LC90 = 0.00203%) or Culicoides imicola Kieffer (24-h LC90 = 0.00773%). In the field, the pour-on formulation was tested with a total of 816 C. nubeculosus specimens fed upon on the thigh of treated sheep. The study revealed a maximum mortality rate of 49% at 4 d postapplication, and duration of lethal effect was predicted to be as short as 10 d, despite testing being carried out with a highly susceptible strain. The reasons for this low efficacy are discussed with reference both to the potential for lack of spread of the active ingredient on the host and feeding patterns of the major potential vector species on the sheep host. Practical implications for vector control strategies during BTV incursions are also detailed.

Trimodality treatment for advanced esophageal cancer: Impact of minimally invasive esophagectomy

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Background: Esophageal cancer is best managed by multimodality therapy, frequently with chemotherapy (C) or chemo- radiotherapy (CRT) preceding resection. Minimally invasive esophagectomy (MIE) is increasingly accepted, but studies of MIE in advanced esophageal and gastroesophageal junction cancer after induction CRT are lacking. This report presents the data on MIE as part of tri-modality therapy for esophageal cancer at Mayo Clinic in Arizona (MCA).

Methods: Patients (pts) who underwent CRT before or after MIE for cancer at MCA between November 2006 and May of 2010 were reviewed retrospectively.

Results: 46 pts (40 males, and 6 females) met study criteria and were reviewed. Median age was 62 years (41-88 years). 45 pts (98%) had adenocarcinoma and one pt had squamous carcinoma. Initial clinical stage was IIA in 10 pts (22%), IIB in 3 pts (7%), III in 26 pts (55%), and IVA in 7 pts (15%) with positive celiac nodes. 43 pts (93%) underwent preoperative CRT with additional intra-operative radiotherapy in 4 pts. Median operating time was 354 min (range 211-567 min), median blood loss was 225 ml (range 50-1,400 ml), and median hospital stay was 8 days (range 5-48 days). 19 pts (41%), including the 3 who did not undergo preoperative CRT, received postoperative C or CRT due to either residual disease at resection or to local recurrence. 30 of 43 pts undergoing MIE after CRT were down staged (11 CR [25.6%], 10 near CR [23.3%]) demonstrating a major response to neoadjuvant therapy in 48.9% of pts. One pt died in hospital (from ARDS and sepsis subsequent to aspiration pneumonia) and two pts died within 30 days of surgery (one from pulmonary embolism, and the other from unknown causes) for a 30 day surgical mortality of 6.5%. 29 pts (63%) had a complication of surgery including 11 (24%) minor and 18 (39%) major complications. After a median follow-up of 13 months (range 0.9-43 months) 16 pts were diagnosed with recurrent disease and 10 of these pts have died of their disease.

Conclusions: CRT with MIE is associated with an acceptable morbidity and mortality level for pts with locally advanced esophageal cancer. These results compare favorably with morbidity, mortality, and recurrence rates in open esophagectomy pts.

No significant financial relationships to disclose.

Evaluation of housing as a means to protect cattle from Culicoides biting midges, the vectors of bluetongue virus

The housing of animals at night was investigated as a possible means of protecting them from attack by Culicoides biting midges (Diptera: Ceratopogonidae), the vectors of bluetongue. Light-trap catches of Culicoides were compared inside and outside animal housing, in the presence and absence of cattle. A three-replicate, 4 x 4 Latin square design was used at four farms in Bala, north Wales, over 12 nights in May and June 2007, and the experiment repeated in October. In the two studies, respectively, >70 000 and >4500 Culicoides were trapped, of which 93% and 86%, respectively, were of the Culicoides obsoletus group. Across the four farms, in May and June, the presence of cattle increased catches of C. obsoletus by 2.3 times, and outside traps caught 6.5 times more insects than inside traps. Similar patterns were apparent in October, but the difference between inside and outside catches was reduced. Catches were strongly correlated with minimum temperature and maximum wind speed and these two variables explained a large amount of night-to-night variation in catch. Outside catches were reduced, to a greater extent than inside catches, by colder minimum temperatures and higher maximum wind speeds. These conditions occur more frequently in October than in May and June, thereby suppressing outside catches more than inside catches, and reducing the apparent degree of exophily of C. obsoletus in autumn. The results suggest that the risk of animals receiving bites from C. obsoletus is reduced by housing at both times of year and the benefit would be greatest on warm, still nights when outside catches are at their greatest.

Variant Creutzfeldt-Jakob disease: the first confirmed case from Portugal shows early onset, long duration and unusual pathology

We present clinical and autopsy findings in the first case of variant Creutzfeldt-Jakob disease diagnosed and confirmed in Portugal. Onset was at 11 years, the earliest onset reported, and the course (32 months) relatively long. Western blot showed protease resistant prion protein, mainly of type 4 (2B) isoform. The cerebral cortex revealed severe spongiform change with numerous amyloid plaques, which did not fit the definition of florid plaques. In the striatum, spongiform change was limited but the extracellular space was dilated. Other reports have found marked spongiform change in the striatum and little in the cortex. Massive neuronal loss, in excess of what has been described, was found in the thalamus and pontine grey. The cerebellum showed, as expected, severe loss of granule cells, moderate loss of Purkinje cells and marked immunopositivity for the prion protein. Differences between our findings and previous ones probably result from the patient's long survival.

Susceptibility of Culicoides biting midge larvae to the insect-pathogenic fungus, Metarhizium anisopliae: prospects for bluetongue vector control

Culicoides biting midges (Diptera: Ceratopogonidae) are responsible for the spread of several arboviruses of livestock and humans that are of international importance. This study assesses the virulence of 18 insect-pathogenic fungal strains from the genera Metarhizium, Beauveria, Isaria and Lecanicillium to larval stages of Culicoides nubeculous Meigen as a means of examining their potential as biocontrol agents. In initial screening, six strains of M. anisopliae (ERL700, CA1, V275, LRC181A, ARSEF 3291 and ARSEF 4556) outperformed the other tested genera and were found to cause between 90% and 100% larval mortality in all larval instars of this species at 72 h post inoculation. The virulence of the most effective strain, M. anisopliae V275, was then further tested by exposing larvae to doses which ranged from 10(4)-10(8) conidia/ml and recording mortality at 24, 48 and 72 h in a 24-multi-well plate with each well containing 600 microl of water and at 24 and 48 h in 250 ml plastic cups containing 50 ml of water. Sensitivity of larvae was extremely high in the multi-well plates, with LC(50) values of 4.3-4.5 x 10(3)conidia/ml and no significant differences between larval instars. In the 250 ml cups, M. anisopliae V275 caused mortalities of between 70% and 100% to larvae and later instars exhibited higher mortality rates. The results are discussed in relation to incorporation of M. anisopliae into biocontrol programmes to control arboviruses vectored by Culicoides.

Sporadic Creutzfeldt-Jakob disease causing a 2-years slowly progressive isolated dementia

A 47-year-old woman was seen for progressive behavioural and cognitive disturbances slowly evolving over a 1-year period. Neuropsychological evaluation disclosed moderate to severe impairment of all cortical functions. Besides this no other clinical abnormality was found. MRI diffusion weighted imaging disclosed hyperintense cortical lesions in a ribbon-like fashion, with restricted diffusivity. EEG showed no periodic sharp waves and CSF examination was normal, including protein 14.3.3. She was heterozygote on codon 129. Her cognitive function continued to decline and she was readmitted for further investigation at the 24th month of disease. Again no ataxia or involuntary movements were observed. MRI disclosed widespread hyperintense lesions over the entire cortex and, for the first time, also caudato-putaminal hyperintensity in T2-weighted images. EEG again failed to show periodic activity. Stereotactic biopsy disclosed moderate spongiform changes, astrocytosis and perivacuolar staining with prion-directed antibodies. Western blot analysis revealed prion type 2 mobility pattern. We discuss the clinical significance of this case: as dementia was the sole finding, and this was slowly-evolving over a 2-year period, MRI findings were the key factor suggesting a prion disease in a woman that otherwise would probably be diagnosed with a primary degenerative dementia.

Life-history parameters of Culicoides (Avaritia) imicola Kieffer in the laboratory at different rearing temperatures

This laboratory study investigates the sub-adult developmental cycle of field collected Culicoides (Avaritia) imicola Kieffer (Diptera; Ceratopogonidae). The period required from blood-feeding field-collected females to the production of progeny adults occupied 34-56 days at 20 degrees C, 15-21 days at 25 degrees C and 11-16 days at 28 degrees C, demonstrating clear temperature dependence. When reared at 28 degrees C, C. imicola demonstrated higher variability in fecundity (between 2.4 and 20.6 eggs/female) and lower hatching rates (50.0-62.2%), although larval survival rates to pupation were low at all temperatures (20-30%). Similarly, the mean emergence rate from pupae was the highest at lower temperatures. These results highlight the difficulty in establishing and maintaining a laboratory colony of this species from field-collected material and results are discussed in reference to future research directions that may aid this process.

Efficacy of alphacypermethrin applied to cattle and sheep against the biting midge Culicoides nubeculosus

The recent emergence of bluetongue virus (BTV) in northern Europe, has led to an urgent need to identify methods to control the Culicoides biting midges that transmit it. Here, an in vitro assay was used to assess the effects of the proprietary pyrethroid insecticide alphacypermethrin applied to cattle and sheep (Dysect Cattle Pour-On, Dysect Sheep Pour-On; Ford Dodge Animal Health) against the biting midge Culicoides nubeculosus (Meigen) (Diptera: Ceratopogonidae). Hair or wool was collected from the back, belly and legs of animals immediately prior to treatment and 7, 14, 21, 28 and 35 days after treatment, and also from untreated controls. In the laboratory assay groups of 10 adult females C. nubeculosus were exposed to 0.5 g of hair or wool for 3 min. In all cases, no mortality was observed in the pre-treatment sample or the untreated controls. In the post-treatment samples, for both cattle and sheep mortality was close to 100% 7 days after treatment. For cattle, treatment effect persisted for up to 21 days post-treatment, following which the mortality rate following exposure to hair samples declined. In contrast, for sheep, mortality levels declined more slowly, and approximately 50% mortality was still observed 35 days after treatment. There was no significant difference in the kill rate for wool collected from the back, belly or legs of either sheep or cattle. The results demonstrate the potential for pour-on insecticide treatment to offer a degree of mitigation to livestock against onward transmission from infected animals--and in particular demonstrate that sufficient compound is able to reach the lower legs to kill in contact midges. The practical issues associated with achieving adequate protection are discussed.

Experimental infection studies of UK Culicoides species midges with bluetongue virus serotypes 8 and 9

This paper describes a rapid, standardised method for testing the susceptibility to bluetongue virus (BTV) of northern Palaearctic Culicoides species midges that can be used to assess the competence of both field-caught and laboratory-infected midges. The method has been used to show that Culicoides scoticus can replicate btv serotype 8 and BTV serotype 9 strains to more than 3 log(10) TCID50/midge, the first evidence of the potential of this species to transmit BTV.