Penile cancer and the HPV attributable fraction in Scotland; A retrospective cohort study.

BACKGROUND: Penile cancer (PeC) is a highly morbid disease which is rising in certain settings including Scotland. A component of PeC is associated with Human Papillomavirus (HPV) although its influence on clinical outcomes is debatable as is whether the fraction attributable to HPV is increasing. METHODS: A total of 122 archived tissue samples derived from patients diagnosed with PeC between 2006-2015 were collated and tested for HPV DNA using molecular PCR. HPV positivity was determined for the overall population and by calendar year of diagnosis to determine any temporal trends. The influence of age, deprivation, smoking, tumour stage and tumour grade on likelihood of HPV positivity was determined by logistic regression. In addition, the influence of HPV status and the other clinical and demographics variables on all-cause death and death from PeC was assessed. RESULTS: HPV was detected in 43 % (95 % CI: 34-52) of penile cancers and the majority of infections were HPV 16. The HPV component of PeC did not increase over the time period (p for linear trend - 0.226). No demographic or clinical variables were associated with HPV positivity neither was HPV status associated with improved all-cause or cancer-specific survival during the follow up period. CONCLUSION: The rise in PeC in Scotland may not be attributable to a rise in HPV-associated cancer; this is consistent with oropharyngeal cancer (OPC) in the UK where there is an increase in both HPV positive and negative cancer. This work calls for a larger multi centre study to enable further detailed investigation into the implications of HPV infection in PeC.

Impact of an influenza information pamphlet on vaccination uptake among Polish pupils in Edinburgh, Scotland and the role of social media in parental decision making.

BACKGROUND: In Edinburgh, Scotland, lower influenza vaccine uptake has been observed in primary school children in the Polish community. METHODS: To address this disparity, the Polish-language version of the NHS Health Scotland influenza information pamphlet was updated and distributed in 2018 to all identified Polish pupils attending three pilot schools. The impact of the revised pamphlet was evaluated by examining changes in vaccine uptake in these schools as compared to a control group of schools, and a questionnaire was issued to all Polish parents in the pilot schools to explore their opinions of the pamphlet and preferred sources of immunisation information. RESULTS: On average uptake was 7.4% (95% CI 1.0-13.8%, p < 0.05) higher in the three pilot schools in which the Polish-language pamphlet was distributed (28.7%) than control schools (21.3%). The questionnaire feedback was that 37.3% of respondents felt better-informed about the influenza vaccine following the pamphlet. The respondents reported that the most important information source in deciding whether to vaccinate is previous experience. Healthcare professionals were ranked lower in importance when making a decision. Parents, who refused consent (n = 65) were more likely to source information from social media, friends and family, and Polish websites compared with those who consented (n = 45). CONCLUSIONS: These findings suggest that issuing new Polish health literature was associated with a large increase in consent form return rate and a modest increase in uptake of the influenza vaccine by Polish pupils in the pilot schools. Social media and Polish websites were found to have a greater influence over Polish parents' decision to immunise than UK healthcare staff and health authority information. Intensive effort is required to encourage parents towards information sources where more accurate pro-vaccination messages can be promulgated by national health services and independent expert groups. The role of social media for migrant communities requires careful consideration, especially for vaccine programmes not delivered in their country of birth.

Vaccines for COVID-19.

Since the emergence of COVID-19, caused by the SARS-CoV-2 virus at the end of 2019, there has been an explosion of vaccine development. By 24 September 2020, a staggering number of vaccines (more than 200) had started preclinical development, of which 43 had entered clinical trials, including some approaches that have not previously been licensed for human vaccines. Vaccines have been widely considered as part of the exit strategy to enable the return to previous patterns of working, schooling and socializing. Importantly, to effectively control the COVID-19 pandemic, production needs to be scaled-up from a small number of preclinical doses to enough filled vials to immunize the world's population, which requires close engagement with manufacturers and regulators. It will require a global effort to control the virus, necessitating equitable access for all countries to effective vaccines. This review explores the immune responses required to protect against SARS-CoV-2 and the potential for vaccine-induced immunopathology. We describe the profile of the different platforms and the advantages and disadvantages of each approach. The review also addresses the critical steps between promising preclinical leads and manufacturing at scale. The issues faced during this pandemic and the platforms being developed to address it will be invaluable for future outbreak control. Nine months after the outbreak began we are at a point where preclinical and early clinical data are being generated for the vaccines; an overview of this important area will help our understanding of the next phases.

Anti-Müllerian hormone in managed African and Asian rhino species.

Serum collected across the lifespan of four managed rhino species: black (Diceros bicornis, n = 16), white (Ceratotherium simum simum, n = 19), greater one-horned (GOH, Rhinoceros unicornis, n = 11) and Sumatran (Dicerorhinus sumatrensis, n = 6) were validated and analyzed in an anti-Müllerian hormone (AMH) enzyme- linked immunoassay. Concentrations of AMH were examined over time, between sexes and throughout different reproductive states which included n = 3 female white rhinos immunocontracepted with porcine zona pellucida (pZP). Across species, males produced higher AMH concentrations compared to females. Among males, AMH concentrations varied by species aside from comparable values secreted between black and white rhinos. The GOH and Sumatran rhino secreted the highest and lowest male AMH concentrations, respectively. However, within each species, AMH concentrations were similar across male age categories. Preliminary insight into male AMH changes from birth to sexual maturity suggest its potential as a marker for onset of testicular maturation. Female black, GOH and Sumatran rhinos secreted comparable AMH concentrations which were higher than those in white rhino. Within each species, inter-individual variation in AMH secretion occurred among females of similar age. While AMH secretion did not differ across the ages sampled for female white (4->26 yr) and GOH (4-26 yr) rhinos, black and Sumatran rhinos >26 and <4 yr, respectively secreted lower AMH compared to conspecific females 7-26 yr of age. Two idiopathic infertility cases corresponded to low (outside species range) AMH values. The establishment of normative AMH concentrations in managed African and Asian rhinos provides an additional metric beyond traditional sex steroids to assess gonadal function. Further work is needed to determine if AMH can predict fertility potential in rhinos.

Comparing vaccination hesitancy in Polish migrant parents who accept or refuse nasal flu vaccination for their children.

This study investigates the background to low uptake of nasal influenza vaccination in Polish pupils in Edinburgh, Scotland. In autumn 2018, one week after their child's nasal flu vaccination sessions, 365 Polish parents were sent a questionnaire exploring influences on their vaccination choices. The questionnaire included a series of 10 vaccine hesitancy questions recommended by the WHO SAGE Working Group on Vaccine Hesitancy. 128 questionnaires were returned representing 43.4% of vaccinated, 41.9% of refusing and 23.8% of non-consent form returning parents. Responses highlighted concerns about side effects, new vaccines and the accuracy of professional advice and information sources. There was complacency expressed about vaccination against diseases that are not common any more. Vaccine refusers were consistently more negative about all aspects vaccination and more likely to answer 'don't know'. Almost half of refusers were uncertain about the quality of health information offered to them. Polish migrants in Scotland come with their beliefs about vaccination and modify these as they acculturate to the UK system. They also continue to be influenced by developments and opinions, norms and values from their home country, as well as diaspora media. We have highlighted issues of concern among Polish migrants as a group and gained additional insights by comparing responses of parents who have refused or accepted vaccination. These insights can inform and target messages and strategies to build confidence and encourage immunisation, which should lead to improved vaccine uptake among ethnic population groups.

Compromised CD4:CD8 ratio recovery in people living with HIV aged over 50 years: an observational study.

OBJECTIVES: Persistent CD4:CD8 ratio inversion (< 1) is associated with mortality in older people. We investigated the interaction of the effects of baseline CD8 count and age at HIV diagnosis on CD4:CD8 ratio recovery with antiretroviral therapy (ART). METHODS: An observational study (1 January 2007 to 31 December 2016) was carried out using routinely collected data from the HIV outpatient services at Imperial College Healthcare NHS Trust, London, UK. CD4 and CD8 counts, prior to and during ART, treatment during primary HIV infection (PHI) and HIV-1 viral load were included in univariate and multivariate analyses using Cox proportional hazard regression. RESULTS: Data were included for 876 patients starting ART, where HIV suppression was achieved. Of these patients, 741 of 876 (84.6%) were male and 507 of 876 (57.9%) were Caucasian. The median time on ART was 38 [interquartile range (IQR) 17-66] months. CD8 count change on ART was bidirectional; low CD8 counts (≤ 600 cells/µL) increased and high CD8 counts (> 900 cells/µL) decreased. The median pre-ART CD4:CD8 ratio was 0.41 (IQR 0.24-0.63), and recovery (≥ 1) occurred in 274 of 876 patients (31.3%). Pre- and post-ART CD4:CD8 ratios were lower in those aged > 50 years compared with young adults aged 18-30 years (P < 0.001 and P = 0.002, respectively). After adjustment, younger age at HIV diagnosis (P < 0.001) and treatment during PHI (P < 0.001) were favourable for CD4:CD8 ratio normalization. CONCLUSIONS: Older age (> 50 years) at HIV diagnosis was associated with persistent CD4:CD8 ratio inversion, whereas treatment of PHI was protective. These findings confirm the need for testing and early treatment of people aged > 50 years, and could be used in a risk management algorithm for enhanced surveillance.

Trained facilitators' experiences with structured advance care planning conversations in oncology: an international focus group study within the ACTION trial.

BACKGROUND: In oncology, Health Care Professionals often experience conducting Advance Care Planning (ACP) conversations as difficult and are hesitant to start them. A structured approach could help to overcome this. In the ACTION trial, a Phase III multi-center cluster-randomized clinical trial in six European countries (Belgium, Denmark, Italy, the Netherlands, Slovenia, United Kingdom), patients with advanced lung or colorectal cancer are invited to have one or two structured ACP conversations with a trained facilitator. It is unclear how trained facilitators experience conducting structured ACP conversations. This study aims to understand how facilitators experience delivering the ACTION Respecting Choices (RC) ACP conversation. METHODS: A qualitative study involving focus groups with RC facilitators. Focus group interviews were recorded, transcribed, anonymized, translated into English, and thematically analysed, supported by NVivo 11. The international research team was involved in data analysis from initial coding and discussion towards final themes. RESULTS: Seven focus groups were conducted, involving 28 of in total 39 trained facilitators, with different professional backgrounds from all participating countries. Alongside some cultural differences, six themes were identified. These reflect that most facilitators welcomed the opportunity to participate in the ACTION trial, seeing it as a means of learning new skills in an important area. The RC script was seen as supportive to ask questions, including those perceived as difficult to ask, but was also experienced as a barrier to a spontaneous conversation. Facilitators noticed that most patients were positive about their ACTION RC ACP conversation, which had prompted them to become aware of their wishes and to share these with others. The facilitators observed that it took patients substantial effort to have these conversations. In response, facilitators took responsibility for enabling patients to experience a conversation from which they could benefit. Facilitators emphasized the need for training, support and advanced communication skills to be able to work with the script. CONCLUSIONS: Facilitators experienced benefits and challenges in conducting scripted ACP conversations. They mentioned the importance of being skilled and experienced in carrying out ACP conversations in order to be able to explore the patients' preferences while staying attuned to patients' needs. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number registry 63110516 ( ISRCTN63110516 ) per 10/3/2014.

A Prospective Cohort Study of Human Papillomavirus-Driven Oropharyngeal Cancers: Implications for Prognosis and Immunisation.

AIMS: Oropharyngeal cancer (OPC) is increasing on a global scale, including the component driven by high-risk human papillomavirus (HR-HPV); contemporary data that provides insight into the prognosis of this disease in addition to the fraction attributable to HR-HPV are essential to inform primary and secondary disease management strategies. MATERIALS AND METHODS: A population-based cohort of 235 patients diagnosed with OPC between 2013 and 2015 in Scotland was assessed for HPV status using molecular genotyping. Associations between HR-HPV status and key clinical and demographic variables were estimated using the Pearson chi-squared test. Rates of overall survival and progression-free survival were estimated and visualised using Kaplan-Meier curves. RESULTS: HPV DNA (largely HPV 16) was identified in 60% of cases. After adjustment for age, gender, deprivation, smoking, alcohol consumption and tumour stage, patients with HR-HPV-positive OPC had an 89% reduction in the risk of death (hazard ratio = 0.11, 95% confidence interval 0.05-0.25) and an 85% reduction in the risk of disease progression (hazard ratio = 0.15, 95% confidence interval 0.07-0.30). HPV positivity was not associated with age, deprivation or smoking status, whereas those who reported excess alcohol consumption were less likely to be positive for HR-HPV. CONCLUSIONS: The prevalence of HR-HPV-associated OPC is high in Scotland and strongly associated with dramatically improved clinical outcomes, including survival. Demographic/behavioural variables did not reliably predict HPV positivity in this cohort, which underlines the importance of laboratory confirmation. Finally, the dominance of HPV 16 in OPC indicates the significant impact of prophylactic immunisation on this disease.

A qualitative study of vaccination behaviour amongst female Polish migrants in Edinburgh, Scotland.

Vaccine hesitancy is increasing and failure to vaccinate is well-recognised in Europe as a contributing factor to outbreaks of infectious diseases. In Lothian and Scotland, low vaccine uptake has been seen in migrants - notably in the Polish group who have arrived since 2004. The recent Vaccine Confidence in European Union report highlights a concerning recent decline in vaccine confidence in Poland. We held three focus groups containing 13 Polish women about the childhood vaccination programme in Lothian, with specific focus on influenza and Human Papillomavirus vaccinations. Key emergent themes were: trust in the national vaccination policy, trust in the vaccination providers (health professionals), trust in the individual vaccines, balancing the risk of disease, and language and communication. Polish norms, beliefs and behaviours shape how Polish migrants navigate the UK health system and its vaccination programme. While not confident in the Scottish primary care model and its generalist practitioners, the participants liked the ethos of informed consent in Scotland and compared this favourably with the compulsory vaccination policy in Poland. There was a belief that vaccines in Scotland were of higher quality than Poland and with fewer adverse effects. Respondents reported returning to Poland for specialist clinical appointments and diagnostic testing. They regularly access Polish clinical expertise and their opinions about health are influenced by Polish friends and family. They say they have difficulty finding official UK Government and health authority vaccination material and often access Polish media, online resources and information. They are familiar with anti-vaccination activities in Poland. Consequently, there are important unmet information needs for this group of parents who may not be making truly informed choices about vaccination. This requires further investigation especially as migration continues and declining immunisation uptake is reported in many countries across Europe.

Evidence of decreased HPV vaccine acceptance in Polish communities within Scotland.

Human papillomavirus (HPV) vaccines are currently utilised globally in national immunisation programmes. Many new European migrants have settled in the United Kingdom (UK) since the 2004 European Union expansion with approximately 91,000 Polish people resident in Scotland. Following anecdotal reports from several NHS Boards within Scotland of lower HPV vaccine uptake in Polish communities compared with other ethnic minorities, an extract containing both forename and surname, was taken from the Scottish Immunisation Recall System (SIRS) for all girls in S2 and S3 in school years 2014/15 to 2016/17. We then used the OnoMap algorithm software to derive ethnicity. OnoMap identified between 289 and 321 age-eligible girls as Polish with significant disparity noted for completed HPV vaccine uptake between UK (87.2-89.8%) and Polish ethnicities (69.7-77.2%) (P < 0.01). Preliminary discussions with Polish families suggest that vaccine programme differences, trust in medical/healthcare practitioners, and cultural influences may be important drivers of acceptance.

Low uptake of nasal influenza vaccine in Polish and other ethnic minority children in Edinburgh, Scotland.

Failure to vaccinate is well-recognised in Europe as a contributing factor to outbreaks of infectious diseases. Low immunisation rates are often associated with religious, social and ethnic minorities, including refugees or migrant groups. Polish people form Scotland's newest and largest migrant group. They have moved to Scotland since 2004, joining established ethnic minorities from China, the Indian subcontinent and Africa. Scotland has had a seasonal influenza nasal vaccination programme for all primary school children since 2013. We investigated three primary schools in Edinburgh, which had reported low influenza vaccination uptake rates in 2016 and 2017 and found that these schools contained many pupils from ethnic minorities, the majority of whom were Polish. Pupils were categorized as one of three ethnic groupings: White British, Polish and Other Identified Ethnic Minority (OIEM). We ascertained ethnicity using NHS and Education Department information sources and name recognition. We examined vaccine acceptance, declination and non-return of consent forms. In 2017, nasal influenza vaccine uptake was 70.7% (65.2-75.6%, p < 0.001) in White British, 60.9% (53.9-67.6%%, p < 0.001) in other identified ethnic minorities and 25.0% (20.9-29.6%, p > 0.001) in Polish children. White British children were more likely to return completed forms (78.9%) than other groups (OIEM 68.2% and Polish 61.8%). 36.8% of Polish families completed a consent form declining vaccination compared to 6.2% of White British families. These findings demonstrate that significant differences exist in nasal influenza vaccination uptake rates, which have important implications for the trans-national study of vaccine hesitancy. Further qualitative work and an investigation of uptake rates of other childhood immunisations in Polish and other migrant groups is required to assess differences in uptake and behaviours.

HPV vaccine uptake in men who have sex with men in Scotland.

Human papillomavirus (HPV) vaccines are currently utilised globally in national immunisation programmes. In July 2017, a national HPV vaccine programme for men who have sex with men (MSM) was initiated across Scotland with vaccine being offered in the sexual health clinic setting. During the first year of this targeted vaccination programme, there were 5905 individuals who received at least one dose of HPV vaccine, representing 63.7% of eligible MSM attendees in this period. Vaccine uptake was relatively stable across all age groups (range 49.8-55.5%). The vaccination programme appears to have dovetailed well with pre-existing sexual health services and appears to be popular with MSM attending the service. The MSM HPV vaccine programme is a robust adjunct to the national girls programme but gender-neutral immunisation will reduce stigma and inequality in HPV-driven disease.

The impact of Recovery Colleges on mental health staff, services and society.

AIMS: Recovery Colleges are opening internationally. The evaluation focus has been on outcomes for Recovery College students who use mental health services. However, benefits may also arise for: staff who attend or co-deliver courses; the mental health and social care service hosting the Recovery College; and wider society. A theory-based change model characterising how Recovery Colleges impact at these higher levels is needed for formal evaluation of their impact, and to inform future Recovery College development. The aim of this study was to develop a stratified theory identifying candidate mechanisms of action and outcomes (impact) for Recovery Colleges at staff, services and societal levels. METHODS: Inductive thematic analysis of 44 publications identified in a systematised review was supplemented by collaborative analysis involving a lived experience advisory panel to develop a preliminary theoretical framework. This was refined through semi-structured interviews with 33 Recovery College stakeholders (service user students, peer/non-peer trainers, managers, community partners, clinicians) in three sites in England. RESULTS: Candidate mechanisms of action and outcomes were identified at staff, services and societal levels. At the staff level, experiencing new relationships may change attitudes and associated professional practice. Identified outcomes for staff included: experiencing and valuing co-production; changed perceptions of service users; and increased passion and job motivation. At the services level, Recovery Colleges often develop somewhat separately from their host system, reducing the reach of the college into the host organisation but allowing development of an alternative culture giving experiential learning opportunities to staff around co-production and the role of a peer workforce. At the societal level, partnering with community-based agencies gave other members of the public opportunities for learning alongside people with mental health problems and enabled community agencies to work with people they might not have otherwise. Recovery Colleges also gave opportunities to beneficially impact on community attitudes. CONCLUSIONS: This study is the first to characterise the mechanisms of action and impact of Recovery Colleges on mental health staff, mental health and social care services, and wider society. The findings suggest that a certain distance is needed in the relationship between the Recovery College and its host organisation if a genuine cultural alternative is to be created. Different strategies are needed depending on what level of impact is intended, and this study can inform decision-making about mechanisms to prioritise. Future research into Recovery Colleges should include contextual evaluation of these higher level impacts, and investigate effectiveness and harms.

CD4:CD8 ratio in children with perinatally acquired HIV-1 infection.

OBJECTIVES: In adults with horizontally acquired HIV infection, an inverted CD4:CD8 ratio is associated with persistent immune activation, size of HIV reservoir and predicts an increased risk of non-AIDS-defining adverse events. Normalization of this ratio with antiretroviral therapy (ART) is suboptimal in adults, despite viral suppression, and is less well described in paediatric populations. We investigated rates of CD4:CD8 ratio recovery in children with perinatally acquired HIV infection (PaHIV) on ART. METHODS: A cross-sectional, retrospective analysis of routine clinical data in children with PaHIV (5-18 years old) attending a single UK centre was carried out. RESULTS: CD4:CD8 normalization was seen in 62% of children on suppressive ART. A negative correlation was found between current CD4:CD8 ratio and age at start of ART. Positive correlations were found between current CD4:CD8 ratio and total time with suppressed HIV viral load and nadir CD4 counts. Multiple linear regression analysis showed that age at start of ART was significantly associated with current CD4:CD8 ratio (standardized ß = -0.680; P < 0.001). Patient sex, ethnicity and antiretroviral regimen did not affect ratio recovery. CONCLUSIONS: We found higher rates of CD4:CD8 ratio normalization compared with previous adult studies. Children who started ART at a younger age were more likely to recover a normal ratio. The current policy of universal treatment for all HIV-positive adults and children will enhance immunological normalization.

Advance care planning: A systematic review about experiences of patients with a life-threatening or life-limiting illness.

BACKGROUND: Advance care planning is seen as an important strategy to improve end-of-life communication and the quality of life of patients and their relatives. However, the frequency of advance care planning conversations in practice remains low. In-depth understanding of patients' experiences with advance care planning might provide clues to optimise its value to patients and improve implementation. AIM: To synthesise and describe the research findings on the experiences with advance care planning of patients with a life-threatening or life-limiting illness. DESIGN: A systematic literature review, using an iterative search strategy. A thematic synthesis was conducted and was supported by NVivo 11. DATA SOURCES: The search was performed in MEDLINE, Embase, PsycINFO and CINAHL on 7 November 2016. RESULTS: Of the 3555 articles found, 20 were included. We identified three themes in patients' experiences with advance care planning. 'Ambivalence' refers to patients simultaneously experiencing benefits from advance care planning as well as unpleasant feelings. 'Readiness' for advance care planning is a necessary prerequisite for taking up its benefits but can also be promoted by the process of advance care planning itself. 'Openness' refers to patients' need to feel comfortable in being open about their preferences for future care towards relevant others. CONCLUSION: Although participation in advance care planning can be accompanied by unpleasant feelings, many patients reported benefits of advance care planning as well. This suggests a need for advance care planning to be personalised in a form which is both feasible and relevant at moments suitable for the individual patient.

An outbreak of mumps with genetic strain variation in a highly vaccinated student population in Scotland.

An outbreak of mumps within a student population in Scotland was investigated to assess the effect of previous vaccination on infection and clinical presentation, and any genotypic variation. Of the 341 cases, 79% were aged 18-24. Vaccination status was available for 278 cases of whom 84% had received at least one dose of mumps containing vaccine and 62% had received two. The complication rate was 5·3% (mainly orchitis), and 1·2% were admitted to hospital. Genetic sequencing of mumps virus isolated from cases across Scotland classified 97% of the samples as genotype G. Two distinct clusters of genotype G were identified, one circulating before the outbreak and the other thereafter, suggesting the virus that caused this outbreak was genetically different from the previously circulating virus. Whilst the poor vaccine effectiveness we found may be due to waning immunity over time, a contributing factor may be that the current mumps vaccine is less effective against some genotypes. Although the general benefits of the measles-mumps-rubella (MMR) vaccine should continue to be promoted, there may be value in reassessing the UK vaccination schedule and the current mumps component of the MMR vaccine.

Posttraumatic stress following spinal cord injury: a systematic review of risk and vulnerability factors.

OBJECTIVES: To summarise quantitatively the available evidence relating to pretraumatic, peritraumatic and posttraumatic characteristics that may increase or decrease the risk of developing posttraumatic stress disorder (PTSD) following spinal cord injury (SCI). STUDY DESIGN: Systematic review. METHODS: Seventeen studies were identified from the PubMed, PsycInfo, Embase, Scopus, CINAHL, Web of Science and PILOTS databases. Effect size estimates (r) with associated 95% confidence intervals (CIs), P-values and fail-safe Ns were calculated. RESULTS: Individual studies reported medium-to-large associations between factors that occurred before (psychiatric history r=0.48 (95% CI, 0.23-0.79) P=0.01) or at the time of injury (tetraplegia r=-0.36 (95% CI, -0.50 to -0.19) P<0.01). Postinjury factors had the strongest pooled effects: depressed mood (rw=0.64, (95% CI, 0.54-0.72)), negative appraisals (rw=0.63 (95% CI, 0.52-0.72)), distress (rw=0.57 (95% CI, 0.50-0.62)), anxiety (rw=0.56 (95% CI, 0.49-0.61)) and pain severity (rw=0.35 (95% CI, 0.27-0.43)) were consistently related to worsening PTSD symptoms (P<0.01). Level of injury significantly correlated with current PTSD severity for veteran populations (QB (1)=18.25, P<0.001), although this was based on limited data. CONCLUSION: Combinations of peri- and post-injury factors appear to be influential in the development of PTSD among persons with SCI. Further studies are needed to extrapolate these findings to the broader spinal cord-injured population. More longitudinal research, driven by multicausal models of causation such as the diathesis-stress model, is also needed to determine the temporality of PTSD risk factors.

Decision-making and future planning for children with life-limiting conditions: a qualitative systematic review and thematic synthesis.

BACKGROUND: In the last decade, the number of children with life-limiting and life-threatening conditions in England has almost doubled, and it is estimated that worldwide, there are 1.2 million children with palliative care needs. Families and professionals caring for children with life-limiting conditions are likely to face a number of difficult treatment decisions and develop plans for future care over the course of the child's life, but little is known about the process by which these decisions and plans are made. METHODS: The purpose of this review is to synthesize findings from qualitative research that has investigated decision-making and future planning for children with life-limiting conditions. A systematic search of six online databases was conducted and identified 887 papers for review; five papers were selected for inclusion, using predefined criteria. Reference list searching and contacting authors identified a further four papers for inclusion. RESULTS: Results sections of the papers were coded and synthesized into themes. Nineteen descriptive themes were identified, and these were further synthesized into four analytical themes. Analytical themes were 'decision factors', 'family factors', 'relational factors' and 'system factors'. CONCLUSIONS: Review findings indicate that decision-making and future planning is difficult and needs to be individualized for each family. However, deficits in understanding the dynamic, relational and contextual aspects of decision-making remain and require further research.

An audit of Cryptosporidium and Giardia detection in Scottish National Health Service Diagnostic Microbiology Laboratories.

Giardia duodenalis and Cryptosporidium species are protozoan parasites capable of causing gastrointestinal disease in humans and animals through the ingestion of infective faeces. Whereas Cryptosporidium species can be acquired locally or through foreign travel, there is the mis-conception that giardiasis is considered to be largely travel-associated, which results in differences in laboratory testing algorithms. In order to determine the level of variation in testing criteria and detection methods between diagnostic laboratories for both pathogens across Scotland, an audit was performed. Twenty Scottish diagnostic microbiology laboratories were invited to participate with questions on sample acceptance criteria, testing methods, testing rates and future plans for pathogen detection. Reponses were received from 19 of the 20 laboratories representing each of the 14 territorial Health Boards. Detection methods varied between laboratories with the majority performing microscopy, one using a lateral flow immunochromatographic antigen assay, another using a manually washed plate-based enzyme immunoassay (EIA) and one laboratory trialling a plate-based EIA automated with an EIA plate washer. Whereas all laboratories except one screened every stool for Cryptosporidium species, an important finding was that significant variation in the testing algorithm for detecting Giardia was noted with only four laboratories testing all diagnostic stools. The most common criteria were 'travel history' (11 laboratories) and/or 'when requested' (14 laboratories). Despite only a small proportion of stools being examined in 15 laboratories for Giardia (2%-18% of the total number of stools submitted), of interest is the finding that a higher positivity rate was observed for Giardia than Cryptosporidium in 10 of these 15 laboratories. These findings highlight that the underreporting of Giardia in Scotland is likely based on current selection and testing algorithms.

Reduction in colposcopy workload and associated clinical activity following human papillomavirus (HPV) catch-up vaccination programme in Scotland: an ecological study.

OBJECTIVE: To measure patterns of clinical activity at colposcopy before and after vaccinated women entered the Scottish Cervical Screening Programme (SCSP). DESIGN: Population-based observational study using nationally collected data. SETTING: Scottish colposcopy clinics. SAMPLE: All women with a date of birth on or after 1 January 1985 who attended colposcopy in Scotland between 2008 and 2014. METHODS: Routinely collected data from the Scottish National Colposcopy Clinical Information Audit System (NCCIAS) were extracted, including: referral criteria, referral cervical cytology, colposcopic findings, clinical procedures, and histology results. Analysis was restricted to those referred to colposcopy at age 20 or 21 years. MAIN OUTCOME MEASURES: Referral criteria, positive predictive value of colposcopy, default rates, and rates of cervical biopsies and treatments. RESULTS: A total of 7372 women referred for colposcopy at age 20 or 21 years were identified. There was a downward trend in the proportion of those referred with abnormal cytology (2008/9, 91.0%; 2013/14, 90.3%; linear trend P = 0.03). Women were less likely to have diagnostic or therapeutic interventions. The proportion with no biopsy (2008/9, 19.5%; 2013/14, 26.9%; linear trend P < 0.0001) and no treatment (2008/9, 74.9%; 2013/14, 91.8%; linear trend P < 0.0001) increased over the period of observation. CONCLUSIONS: A reduction in clinical activity related to abnormal screening referrals is likely to be associated with the human papillomavirus (HPV) catch-up immunisation programme. Referral criteria and the service provision of colposcopy needs to be planned carefully, taking account of the increasing number of women who have been immunised against HPV that will be entering cervical screening programmes worldwide. TWEETABLE ABSTRACT: Colposcopy referral criteria and service planning need attention following HPV immunisation programme.