Intravaginal immunisation using a novel antigen-releasing ring device elicits robust vaccine antigen-specific systemic and mucosal humoral immune responses

The generation of effective levels of antigen-specific immunity at the mucosal sites of pathogen entry is a key goal for vaccinologists. We explored topical vaginal application as an approach to initiate local antigen-specific immunity, enhance previously existing systemic immunity or re-target responses to the mucosae. To deliver a protein vaccine formulation to the vaginal mucosal surface, we used a novel vaginal ring device comprising a silicone elastomer body into which three freeze-dried, rod-shaped, hydroxypropylmethylcellulose inserts were incorporated. Each rod contained recombinant HIV-1 CN54gp140 protein (167μg)±R848 (167μg) adjuvant. The inserts were loaded into cavities within each ring such that only the ends of the inserts were initially exposed. Sheep received a prime-boost vaccination regime comprising intramuscular injection of 100μg CN54gp140+200μg R848 followed by three successive ring applications of one week duration and separated by one month intervals. Other sheep received only the ring devices without intramuscular priming. Serum and vaginal mucosal fluids were sampled every two weeks and analysed by CN54gp140 ELISA and antigen-specific B cells were measured by flow cytometry at necropsy. Vaccine antigen-specific serum antibody responses were detected in both the intramuscularly-primed and vaginal mucosally-primed groups. Those animals that received only vaginal vaccinations had identical IgG but superior IgA responses. Analysis revealed that all animals exhibited mucosal antigen-specific IgG and IgA with the IgA responses 30-fold greater than systemic levels. Importantly, very high numbers of antigen-specific B cells were detected in local genital draining lymph nodes. We have elicited local genital antigen-specific immune responses after topical application of an adjuvanted antigen formulation within a novel vaginal ring vaccine release device. This regimen and delivery method elicited high levels of antigen-specific mucosal IgA and large numbers of local antigen-reactive B cells, both likely essential for effective mucosal protection.

Childhood bullying victimization is associated with use of mental health services over five decades: a longitudinal nationally representative cohort study

BACKGROUND

Research supports robust associations between childhood bullying victimization and mental health problems in childhood/adolescence and emerging evidence shows that the impact can persist into adulthood. We examined the impact of bullying victimization on mental health service use from childhood to midlife.

METHOD

We performed secondary analysis using the National Child Development Study, the 1958 British Birth Cohort Study. We conducted analyses on 9242 participants with complete data on childhood bullying victimization and service use at midlife. We used multivariable logistic regression models to examine associations between childhood bullying victimization and mental health service use at the ages of 16, 23, 33, 42 and 50 years. We estimated incidence and persistence of mental health service use over time to the age of 50 years.

RESULTS

Compared with participants who were not bullied in childhood, those who were frequently bullied were more likely to use mental health services in childhood and adolescence [odds ratio (OR) 2.53, 95% confidence interval (CI) 1.88-3.40] and also in midlife (OR 1.30, 95% CI 1.10-1.55). Disparity in service use associated with childhood bullying victimization was accounted for by both incident service use through to age 33 years by a subgroup of participants, and by persistent use up to midlife.

CONCLUSIONS

Childhood bullying victimization adds to the pressure on an already stretched health care system. Policy and practice efforts providing support for victims of bullying could help contain public sector costs. Given constrained budgets and the long-term mental health impact on victims of bullying, early prevention strategies could be effective at limiting both individual distress and later costs.

Communication with Physicians about Health Care Costs: Survey of an Insured Population

CONTEXT

Health care costs have increasingly shifted to patients, and financial distress caused by medical care has increased. Patients may wish to discuss costs with their clinicians.

OBJECTIVE

Describe patient preferences for communication about cost in the clinical setting.

DESIGN

Cross-sectional, self-administered survey of a stratified random sample of the population insured in an integrated health care system in Washington State. Our sampling frame was the entire membership aged 21 years or older. Sampling was stratified by sex and group practice enrollment.

MAIN OUTCOME MEASURES

Preference for discussing health care costs with one's physician. We conducted regression analyses to determine predictors of communication preference; potential predictors included demographic characteristics, financial burden, delay in seeking care because of cost, and socioeconomic variables. Survey responses were weighted to adjust for nonresponse and sampling.

RESULTS

Of 7200 invitations sent, 2200 survey responses were returned. Ninety-two percent wished to know their out-of-pocket costs before beginning treatment. Most respondents preferred their physician talk with them about out-of-pocket costs (81.4%) and expressed comfort with discussing costs with their physician (75.6%). Overall, 43.7% reported any delay in seeking care in the previous 12 months. One in 5 respondents (21.6%) reported family medical debt. Delay in seeking care was positively and independently associated with preferring to discuss costs with one's physician; current medical financial burden was not.

CONCLUSION

Patient preferences for communication about costs with physicians are high, and medical debt and delay in care-seeking are prevalent. Delay in care-seeking independently predicts cost communication preferences.

The Influence of Head Impact Threshold for Reporting Data in Contact and Collision Sports: Systematic Review and Original Data Analysis

BACKGROUND

Head impacts and resulting head accelerations cause concussive injuries. There is no standard for reporting head impact data in sports to enable comparison between studies.

OBJECTIVE

The aim was to outline methods for reporting head impact acceleration data in sport and the effect of the acceleration thresholds on the number of impacts reported.

METHODS

A systematic review of accelerometer systems utilised to report head impact data in sport was conducted. The effect of using different thresholds on a set of impact data from 38 amateur senior rugby players in New Zealand over a competition season was calculated.

RESULTS

Of the 52 studies identified, 42% reported impacts using a >10-g threshold, where g is the acceleration of gravity. Studies reported descriptive statistics as mean ± standard deviation, median, 25th to 75th interquartile range, and 95th percentile. Application of the varied impact thresholds to the New Zealand data set resulted in 20,687 impacts of >10 g, 11,459 (45% less) impacts of >15 g, and 4024 (81% less) impacts of >30 g.

DISCUSSION

Linear and angular raw data were most frequently reported. Metrics combining raw data may be more useful; however, validity of the metrics has not been adequately addressed for sport. Differing data collection methods and descriptive statistics for reporting head impacts in sports limit inter-study comparisons. Consensus on data analysis methods for sports impact assessment is needed, including thresholds. Based on the available data, the 10-g threshold is the most commonly reported impact threshold and should be reported as the median with 25th and 75th interquartile ranges as the data are non-normally distributed. Validation studies are required to determine the best threshold and metrics for impact acceleration data collection in sport.

CONCLUSION

Until in-field validation studies are completed, it is recommended that head impact data should be reported as median and interquartile ranges using the 10-g impact threshold.

Arthrodesis of the Subtalar Joint in a High School Football Player With a Talocalcaneal Coalition: Case Report With Functional Analysis

Tarsal coalition is a bony or fibrous bridge between 2 tarsal bones. The condition is typically congenital and presents in early to mid-adolescence. Common symptoms include ankle pain, stiffness, and limited range of motion. Conservative treatment of tarsal coalition consists of immobilization, short leg walking cast, steroid injections, physical therapy, ankle braces, and orthotics. When conservative care fails, surgical intervention for tarsal coalition includes excision of the coalition or joint arthrodesis. We present a case of a high school football player with a 5-year history of left ankle pain secondary to a talocalcaneal coalition. The athlete did not respond favorably to conservative treatment and underwent a subtalar joint arthrodesis. Prior to surgery, the athlete consented to self-reported functional outcome measures, range of motion measures, and 3D video gait analysis to evaluate the effects of surgery. Measurements were taken prior to surgery and 1½ years after surgery. Clinically significant improvements were seen in subjective outcome measures and functional ankle range of motion in this case. There is limited research available to validate long-term outcomes for current conservative and surgical treatments of tarsal coalition. In this case, joint arthrodesis resulted in a good long-term outcome for this athlete.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case study.

Population-based outreach versus care as usual to prevent suicide attempt: study protocol for a randomized controlled trial

BACKGROUND

Suicide remains the 10th-ranked most frequent cause of death in the United States, accounting for over 40,000 deaths per year. Nonfatal suicide attempts lead to over 200,000 hospitalizations and 600,000 emergency department visits annually. Recent evidence indicates that responses to the commonly used Patient Health Questionnaire (PHQ9) can identify outpatients who are at risk of suicide attempt and suicide death and that specific psychotherapy or Care Management programs can prevent suicide attempts in high-risk patients. Motivated by these developments, the NIMH-funded Mental Health Research Network has undertaken a multisite trial of two outreach programs to prevent suicide attempts among outpatients identified by routinely administered PHQ9 questionnaires.

METHODS/DESIGN

Outpatients who are at risk of suicide attempt are automatically identified using data from electronic health records (EHRs). Following a modified Zelen design, all those identified are assigned to continued usual care (i.e., no contact) or to be offered one of two population-based outreach programs. A Care Management intervention includes systematic outreach to assess suicide risk, EHR-based tools to implement risk-based care pathways, and care management to facilitate recommended follow-up. A Skills Training intervention includes interactive online training in Dialectical Behavior Therapy skills, supported by reminder and reinforcement messages from a skills coach. Each intervention supplements, rather than replaces, usual care; participants may receive any other services normally available. Interventions are delivered primarily by secure messaging through EHR patient portals. Suicide attempts and deaths following randomization are identified using state vital statistics data and health system EHR and insurance claim data. Primary evaluation will compare risk of suicide attempt or death over 18 months according to the initial assignment, regardless of intervention participation. Recruitment is underway in three health systems (Group Health Cooperative, HealthPartners, and Kaiser Permanente Colorado). Over 2500 participants have been randomized as of 1 March 2016, with enrollment averaging approximately 100 per week.

DISCUSSION

Assessing the effectiveness of population-based suicide prevention requires adherence to the principles of pragmatic trials: population-based enrollment, accepting variable treatment participation, assessing outcomes using health record data, and analyses based on intent-to-treat.

TRIAL REGISTRATION

ClinicalTrials.gov registration # NCT02326883 , registered on 23 December 2014.

Using a blended e-learning model to provide accessible infection prevention and control training for NHS staff: The NHSU/TVU/Intuition approach

ver the past two decades, healthcare-associated infections (HCAI) have emerged as a significant threat to high quality health care. The technological advances made in the treatment of many diseases and disorders are being undermined by the transmission of infections within healthcare settings, especially the emergence of antimicrobial resistant strains of Staphylococcus aureus and enterococci that are now endemic in some healthcare environments. The financial and personal costs of HCAI in terms of the economic consequences to the National Health Service (NHS) and the physical, social and psychological costs to patients and their relatives have increased both government and public awareness of the risks associated with healthcare interventions and in particular the consequences of HCAI.

The risk of acquiring HCAI continues to attract intense media interest. Reports of dirty hospitals and stories of healthcare workers failing to observe even the most rudimentary hygiene and other infection prevention and control measures are causing profound anxiety among service users. The public is fast losing confidence in the NHS to safely care for them and this dissatisfaction has propelled HCAI to the top of an increasingly urgent political healthcare agenda.

The Department of Health (DH) has focused a number of initiatives on combating HCAI, including the development of national evidence-based infection prevention and control guidelines for acute and primary care settings (Pratt et al, 2001; Pellowe et al, 2003), a research programme to identify a range of effective strategies for combating antimicrobial resistance and more recently setting out a strategy for reducing HCAI and improving environmental hygiene in healthcare settings (DH, 2002; DH, 2004). DH strategy emphasises the importance of ensuring that infection prevention and control training is included in the induction programme for all NHS staff, both clinical and nonclinical, including agency and locum staff, and that this training becomes part of their continuing personal development plans.

Professor Christine Beasley, the chief nursing officer at the DH has since taken responsibility for actualising many aspects of this strategy, especially ensuring that the required training is made available for all 1.3 million NHS staff by the end of 2005. Providing that training became the responsibility of the NHS University (NHSU), which commissioned the Richard Wells Research Centre at Thames Valley University London (TVU) along with their Dublin-based educational development partner, Intuition Publishing Ltd, to develop an appropriate and accessible state-of-the-art blended e-learning training programme.

In this article, we describe how we designed and structured the programme so that it can be used as an essential tool in orientation/induction, staff development and in-service education programmes for all NHS staff.

The 'S' test - a preliminary study of an instrument for selecting the most appropriate mobility aid

Objective: To develop and evaluate a qualitative and quantitative instrument for selecting the ideal mobility aid for those with mobility disorders.

Setting: A district general hospital-based geriatric unit.

Subjects: Elderly inpatients and outpatients with mobility disorders.

Interventions: Structured assessments with different mobility aids to select the most suitable.

Outcome measures: Safety, stance, stability, step/stride pattern and speed were considered.

Results: The 'S' test successfully selected an aid for all 49 subjects. For most this aid offered marked improvement in qualitative and quantitative aspects of gait when compared with the subject's usual aid.

Conclusions: The 'S' test is an effective tool for selecting mobility aids within an institutional setting.

HPV Vaccine Public Awareness Campaigns: An Environmental Scan

Human papillomavirus (HPV) vaccination rates are significantly lower than recommended targets. Public awareness campaigns can raise awareness of the severity and prevalence of HPV infection and the cancer prevention benefits of the vaccine. We conducted an environmental scan of HPV vaccine public awareness campaigns during the summer of 2014. We used online search strategies and expert input to identify candidate campaigns. Multiple study investigators reviewed all data abstraction and analysis. After applying our inclusion criteria, we identified 14 campaigns with parents or teenagers as the target audience. We characterized campaign messages according to constructs of the Health Belief Model. Most messages focused on the cancer prevention benefits of HPV vaccine; few addressed psychological or practical barriers to getting or completing the vaccine. Four of 14 campaigns had pre- or postcampaign data readily available, only 2 used vaccine outcomes in their evaluations. We concluded there was a high prevalence of HPV vaccine public awareness campaigns but little available evidence on their impact on intermediate or vaccine outcomes.

Use of the King-Devick test for sideline concussion screening in junior rugby league

AIM

To determine whether the King-Devick (K-D) test used as a sideline test in junior rugby league players over 12 matches in a domestic competition season could identify witnessed and incidentally identified episodes of concussion.

METHODS

A prospective observational cohort study of a club level junior rugby league team (n=19) during the 2014 New Zealand competition season involved every player completing two pre-competition season baseline trials of the K-D test. Players removed from match participation, or who reported any signs or symptoms of concussion were assessed on the sideline with the K-D test and referred for further medical assessment. Players with a pre- to post-match K-D test difference >3s were referred for physician evaluation.

RESULTS

The baseline test-retest reliability of the K-D test was high (rs=0.86; p<0.0001). Seven concussions were medically identified in six players who recorded pre- to post-match K-D test times greater than 3s (mean change of 7.4s). Post-season testing of players demonstrated improvement of K-D time scores consistent with learning effects of using the K-D test (67.7s vs. 62.2s).

DISCUSSION

Although no witnessed concussions occurred during rugby play, six players recorded pre- to post-match changes with a mean delay of 4s resulting in seven concussions being subsequently confirmed post-match by health practitioners. All players were medically managed for a return to sports participation.

CONCLUSION

The K-D test was quickly and easily administered making it a practical sideline tool as part of the continuum of concussion assessment tools for junior rugby league players.

Protecting a CT simulator room to accommodate a cyberknife facility

In 2012, a plan to develop Stereotactic treatments using a Cyberknife was unveiled at the Hermitage Medical Clinic, Dublin. Due to planning restrictions the new facility had to be contained in the existing hospital's blue print with the only available location being an unused CT simulation room. The room design would be different from conventional radiotherapy bunkers due to the fact the Cyberknife can fire an unfiltered beam in any direction bar the roof (restriction of 22° above the horizontal). Therefore all walls must be primary barriers with the roof designed to protect against the large leakage radiation resulting from the high MU's used during the treatments. Space consideration indicated that concrete alone could not be used to restrict the radiation beam to acceptable limits. To this end a combination of steel, lead, normal and heavy concrete were used to meet the dose constraints established by the Irish licensing authorities.

Development of secondary mutations in wild-type and mutant EZH2 alleles cooperates to confer resistance to EZH2 inhibitors

The histone methyltransferase Enhancer of Zeste Homolog 2 (EZH2) is frequently dysregulated in cancers, and gain-of-function (GOF) EZH2 mutations have been identified in non-Hodgkin lymphomas. Small-molecule inhibitors against EZH2 demonstrated anti-tumor activity in EZH2-mutated lymphomas and entered clinical trials. Here, we developed models of acquired resistance to EZH2 inhibitor EI1 with EZH2-mutated lymphoma cells. Resistance was generated by secondary mutations in both wild-type (WT) and GOF Y641N EZH2 alleles. These EZH2 mutants retained the substrate specificity of their predecessor complexes but became refractory to biochemical inhibition by EZH2 inhibitors. Resistant cells were able to maintain a high level of H3K27Me3 in the presence of inhibitors. Interestingly, mutation of EZH2 WT alone generated an intermediate resistance phenotype, which is consistent with a previously proposed model of cooperation between EZH2 WT and Y641N mutants to promote tumorigenesis. In addition, the findings presented here have implications for the clinical translation of EZH2 inhibitors and underscore the need to develop novel EZH2 inhibitors to target potential resistance emerging in clinical settings.