Patient preferences for stratified medicine in psoriasis: a discrete choice experiment.

BACKGROUND: New technologies have enabled the potential for stratified medicine in psoriasis. It is important to understand patients' preferences to enable the informed introduction of stratified medicine, which is likely to involve a number of individual tests that could be collated into a prescribing algorithm for biological drug selection to be used in clinical practice. OBJECTIVES: To quantify patient preferences for an algorithm-based approach to prescribing biologics ('biologic calculator') in psoriasis. METHODS: An online survey comprising a discrete choice experiment (DCE) was conducted to elicit the preferences of two purposive samples of adults living with psoriasis in the UK, identified from a psoriasis patient organization (Psoriasis Association) and an online panel provider (Dynata). Respondents chose between two biologic calculators and conventional prescribing described using five attributes: treatment delay; positive predictive value; negative predictive value; risk of infection; and cost saving to the National Health Service. Each participant selected their preferred alternative from six hypothetical choice sets. Additional data, including sociodemographic characteristics, were collected. Choice data were analysed using conditional logit and fully correlated random parameters logit models. RESULTS: Data from 212 respondents (67 from the Psoriasis Association and 145 from Dynata) were analysed. The signs of all estimated coefficients were consistent with a priori expectations. Respondents had a strong preference for a high predictive accuracy and avoiding serious infection, but there was evidence of systematic differences in preferences between the samples. CONCLUSIONS: This study indicates that individuals with psoriasis would value a biologic calculator and suggested that such a biologic calculator should have sufficient accuracy to predict future response and risk of serious infection from the biologic.

Causes of Mortality and Lesions Observed Post mortem in European Moles (Talpa europaea) in Cornwall, South-west England.

European moles (Talpa europaea) are a common species in the UK, but there are few published data on the causes of mortality in these animals. An opportunistic post-mortem study was carried out on 44 moles found dead or dying in Cornwall, UK. Assessment of muscle condition and fat reserves, where possible, indicated that most (27 of 37, 73%) were in good nutritive condition. The majority had died of trauma (n = 40, 91%), the principal cause of which was predation (n = 36, 81.8%) by foxes and domestic cats and dogs. The carcases were in a variable state of preservation, but 28 cases were suitable for histopathological examination. This revealed lesions in the lungs of 92.8 % (26 of 28) of the animals. The commonest lesions comprised localized infiltration of the parenchyma by macrophages and eosinophils and in most cases the lesions were unlikely to have been of clinical significance; in two cases they were associated with infection by a parasitic nematode. One mole showed severe pneumonitis and hepatitis caused by infection with Toxoplasma gondii. Adiaspiromycosis was diagnosed in two moles, one by direct microscopical examination of the lung and one by histopathology; the lesions were not considered to be of clinical significance. Severe pleurisy and pericarditis caused by infection with Streptobacillus moniliformis was seen in a mole that had suffered bite wounds to a foot previously. Cholangitis due to infection by a protozoal parasite, provisionally identified as Cyclospora talpae, was a common histopathological finding (11 of 28, 39.3%); infection by the parasite did not appear to affect body condition adversely. Miscellaneous conditions identified were ulcerative dermatitis associated with gram-positive cocci (n = 1), extra medullary haemopoiesis in spleens (six of 12, 50%) and mineralized foci in pulmonary blood vessels (three of 28, 10.7%). No significant pathology was seen in the kidneys. This study suggests that the health status of moles in Cornwall is generally good and predation is a common cause of mortality. Pulmonary disease, associated in some cases with nematode infections, is also prevalent, but probably of little clinical significance. There is a high prevalence of cholangitis due to infection with a protozoan parasite believed to be C. talpae. Other diseases identified include adiaspiromycosis, streptobacillosis and toxoplasmosis.

Microplastics in marine mammals stranded around the British coast: ubiquitous but transitory?

Plastic pollution represents a pervasive and increasing threat to marine ecosystems worldwide and there is a need to better understand the extent to which microplastics (<5 mm) are ingested by high trophic-level taxa, such as marine mammals. Here, we perform a comprehensive assessment by examining whole digestive tracts of 50 individuals from 10 species whilst operating strict contamination controls. Microplastics were ubiquitous with particles detected in every animal examined. The relatively low number per animal (mean = 5.5) suggests these particles are transitory. Stomachs, however, were found to contain a greater number than intestines, indicating a potential site of temporary retention. The majority of particles were fibres (84%) while the remaining 16% was fragments. Particles were mainly blue and black (42.5% and 26.4%) in colour and Nylon was the most prevalent (60%) polymer type. A possible relationship was found between the cause of death category and microplastic abundance, indicating that animals that died due to infectious diseases had a slightly higher number of particles than those that died of trauma and other drivers of mortality. It is not possible, however, to draw any firm conclusions on the potential biological significance of this observation and further research is required to better understand the potential chronic effects of microplastic exposure on animal health, particularly as marine mammals are widely considered important sentinels for the implications of pollution for the marine environment.

Identification of factors that may influence the selection of first-line biological therapy for people with psoriasis: a prospective, multicentre cohort study.

BACKGROUND: The Psoriasis Stratification to Optimise Relevant Therapy (PSORT) consortium has a collective aim to develop a prescribing algorithm to help stratify eligible patients with psoriasis to the most appropriate biological treatment. To facilitate the adoption of a stratified approach, it is necessary to first understand the factors driving the choice of first-line biological therapy. OBJECTIVES: To identify and quantify factors that influence the selection of the first-line biological therapy for people with psoriasis. METHODS: Multinomial logistic regression was used to determine the factors that influenced the probability of treatment selection, using data from the British Association of Dermatologists Biologic Interventions Register from January 2012 to December 2015. Sensitivity analyses were performed to assess the robustness of the findings to key assumptions. RESULTS: The main analysis was based on a dataset comprising 3040 people with psoriasis. The identified factors affecting first-line biological selection within the available therapies were: presence of psoriatic arthritis; patient weight; employment status; country of registration; and baseline disease severity. Importantly, the analysis showed a general shift in prescribing behaviour over time. These results were robust to sensitivity analysis. CONCLUSIONS: This study offers important insights into the factors influencing current prescribing practice for first-line biological therapies for people with psoriasis. It provides baseline data to inform the evaluation of future potential changes that may affect prescribing behaviour, such as stratified medicine.

Influence of surface microstructure and chemistry on osteoinduction and osteoclastogenesis by biphasic calcium phosphate discs.

It has been reported that surface microstructural dimensions can influence the osteoinductivity of calcium phosphates (CaPs), and osteoclasts may play a role in this process. We hypothesised that surface structural dimensions of ≤ 1 µm trigger osteoinduction and osteoclast formation irrespective of macrostructure (e.g., concavities, interconnected macropores, interparticle space) or surface chemistry. To test this, planar discs made of biphasic calcium phosphate (BCP: 80% hydroxyapatite, 20% tricalcium phosphate) were prepared with different surface structural dimensions - either ~ 1 µm (BCP1150) or ~ 2-4 µm (BCP1300) - and no macropores or concavities. A third material was made by sputter coating BCP1150 with titanium (BCP1150Ti), thereby changing its surface chemistry but preserving its surface structure and chemical reactivity. After intramuscular implantation in 5 dogs for 12 weeks, BCP1150 formed ectopic bone in 4 out of 5 samples, BCP1150Ti formed ectopic bone in 3 out of 5 samples, and BCP1300 formed no ectopic bone in any of the 5 samples. In vivo, large multinucleated osteoclast-like cells densely colonised BCP1150, smaller osteoclast-like cells formed on BCP1150Ti, and osteoclast-like cells scarcely formed on BCP1300. In vitro, RAW264.7 cells cultured on the surface of BCP1150 and BCP1150Ti in the presence of osteoclast differentiation factor RANKL (receptor activator for NF-κB ligand) proliferated then differentiated into multinucleated osteoclast-like cells with positive tartrate resistant acid phosphatase (TRAP) activity. However, cell proliferation, fusion, and TRAP activity were all significantly inhibited on BCP1300. These results indicate that of the material parameters tested - namely, surface microstructure, macrostructure, and surface chemistry - microstructural dimensions are critical in promoting osteoclastogenesis and triggering ectopic bone formation.

Submicron-scale surface architecture of tricalcium phosphate directs osteogenesis in vitro and in vivo.

A current challenge of synthetic bone graft substitute design is to induce bone formation at a similar rate to its biological resorption, matching bone's intrinsic osteoinductivity and capacity for remodelling. We hypothesise that both osteoinduction and resorption can be achieved by altering surface microstructure of beta-tricalcium phosphate (TCP). To test this, two TCP ceramics are engineered with equivalent chemistry and macrostructure but with either submicron- or micron-scale surface architecture. In vitro, submicron-scale surface architecture differentiates larger, more active osteoclasts--a cell type shown to be important for both TCP resorption and osteogenesis--and enhances their secretion of osteogenic factors to induce osteoblast differentiation of human mesenchymal stem cells. In an intramuscular model, submicrostructured TCP forms 20 % bone in the free space, is resorbed by 24 %, and is densely populated by multinucleated osteoclast-like cells after 12 weeks; however, TCP with micron-scale surface architecture forms no bone, is essentially not resorbed, and contains scarce osteoclast-like cells. Thus, a novel submicron-structured TCP induces substantial bone formation and is resorbed at an equivalent rate, potentially through the control of osteoclast-like cells.

Association of a lukM-positive clone of Staphylococcus aureus with fatal exudative dermatitis in red squirrels (Sciurus vulgaris).

Fatal exudative dermatitis (FED) is a recently described condition affecting red squirrels (Sciurus vulgaris) on the Isle of Wight and Jersey (Simpson et al., 2010a). Staphylococcus aureus strains isolated from skin lesions in cases of FED were characterised by molecular and phenotypic approaches. The strains were found to belong to a single MLST clonal complex (CC49) representing either ST49 or a novel single locus variant thereof (ST1957), were closely related by other molecular typing approaches, and all possessed the leukotoxin M encoding gene (lukM). In contrast S. aureus was either not isolated from none-FED cases or belonged to distinct and diverse molecular types that, with one exception, did not encode lukM. All isolates from FED cases were susceptible to all antimicrobials tested, including penicillin, and all proved negative for mecA and mecC as well as 14 other staphylococcal toxin genes. As all squirrels affected by FED were infected with S. aureus of the same lineage and encoded the lukM gene, it is possible that strains of this lineage may be involved in the pathogenesis of the dermatitis.

Infection with Brucella ceti and high levels of polychlorinated biphenyls in bottlenose dolphins (Tursiops truncatus) stranded in south-west England.

Eight bottlenose dolphins (Tursiops truncatus) that stranded in Cornwall, south-west England, between June 2004 and December 2007 were examined using standardised postmortem examination and bacteriological methods. Evidence of Brucella species infection was found in four of these dolphins on culture. In addition, of the eight dolphins, four were positive and two were weakly positive for antibodies to Brucella species on serological analyses of pericardial and other fluids using a competitive ELISA and two indirect ELISAs. High or very high levels of the sum of 25 individual chlorobiphenyl congeners (∑25CBs) were also determined in blubber samples from two of the dolphins (45.5 and 446.6 mg/kg lipid weight).

True hermaphroditism: first evidence of an ovotestis in a cetacean species.

An immature unilateral hermaphrodite common dolphin (Delphinus delphis) was found stranded on the southwest coast of the UK. The external phenotype was that of a female, but internally there was one ovotestis, containing both ovarian follicles and testicular tubular elements, and a contralateral ovary. Ovarian portions of the ovotestis appeared normal and demonstrated follicular development, whereas the testicular tissue exhibited hypoplasia and degeneration. This is the first reported case of an ovotestis in a cetacean species.

Prevalence of a host-adapted group B Salmonella enterica in harbour porpoises (Phocoena phocoena) from the south-west coast of England.

A monophasic group B Salmonella enterica 4,12:a:- was first isolated in harbour porpoises (Phocoena phocoena) in Scotland in 1991. This paper reports the isolation of the same group B S enterica from harbour porpoise carcases found stranded along the Cornwall and Devon coastlines. Between 1991 and 2002, 80 harbour porpoises were submitted for postmortem examination and subjected to bacteriological examination under the UK Cetacean Strandings Investigation Programme. A total of 28 Salmonella isolates were recovered and subjected to several tests, including biochemical, molecular and serological analysis.

Postmortem evidence of interactions of bottlenose dolphins (Tursiops truncatus) with other dolphin species in south-west England.

Reports of violent interactions between bottlenose dolphins (Tursiops truncatus) and harbour porpoises (Phocoena phocoena) in the coastal waters of the UK are well documented. Examination of stranded cetaceans by the Cornwall Wildlife Trust Marine Strandings Network and the UK Cetacean Strandings Investigation Programme has indicated that seven animals, of four other species, found stranded in south-west England, had pathology consistent with bottlenose dolphin interaction, including two juvenile and two adult common dolphins (Delphinus delphis), one juvenile pilot whale (Globicephala melas), one juvenile Risso's dolphin (Grampus griseus) and one adult striped dolphin (Stenella coeruleoalba). Although recorded traumatic lesions were often not as severe as those found in harbour porpoises, it is probable that the interactions did contribute to stranding and/or death in all four of the juvenile animals examined. Furthermore, analysis of photographs taken before establishment of the Marine Strandings Network revealed rake (teeth) marks consistent with bottlenose dolphin interaction on one stranded common dolphin in 1992. A number of causes have been suggested for these interactions in harbour porpoises stranded in the UK and it is possible that any combination of these factors may also be implicated in the cases described in this report.

Isolation and characterization of Brucella from the lungworms of a harbor porpoise (Phocoena phocoena).

Adult female nematodes identified as Pseudalius inflexus were collected from the lungs of a juvenile male harbor porpoise (Phocoena phocoena) found dead on a beach in Cornwall, UK. Classic and molecular typing methods, immunologic and electron microscopy immunolabeling techniques, provided evidence of Brucella sp. infection within the uterine tissue of nematodes of this marine mammal. This finding presents further evidence to suggest parasites should be considered as a potential means of transfer of bacterial infection in marine mammals and highlights the zoonotic implications for humans exposed to marine mammals through occupation or leisure.

Hepatozoon species infection in wild red squirrels (Sciurus vulgaris) on the Isle of Wight.

Postmortem examinations of 49 red squirrels (Sciurus vulgaris) found dead on the Isle of Wight revealed the presence of a Hepatozoon species in 18 of them (37 per cent). The prevalence of infection was highest in subadult animals and no juveniles were infected. The prevalence was higher in the squirrels dying from natural causes (nine of 12) than in squirrels killed in road accidents (seven of 27). The weight of infection varied, and there were heavy infections in squirrels dying from toxoplasmosis and bacterial pneumonia. A PCR-based assay was used to identify the presence of Hepatozoon species DNA in the lungs, and immunoperoxidase staining was used to confirm the identity of schizonts observed in histological sections. The nucleotide base sequence of the PCR products indicated that the organism was a novel species closely related to, but distinct from, Hepatozoon erhardovae of bank voles (Clethrionomys glareolus).