Law, Ethics and Lockdowns: Impacts on Life, Liberty and the Economy.

Many people worldwide, particularly those with disabilities and the elderly, suffered greatly not only as a result of the Covid-19 pandemic but also as a result of the lockdowns. In this article we set out widely-accepted ethical criteria for assessing when coercive public health measures are justified. We then review the empirical evidence, not least concerning the benefits and costs of the lockdowns, and conclude that lockdowns as instituted in the UK (and, presumptively, in many other jurisdictions) appeared to breach those criteria. We conclude that any future proposal to lockdown should be subjected to the strictest ethical scrutiny, and that a lockdown should not be contemplated unless it could be convincingly demonstrated that the benefits would substantially outweigh the harms; that it would be proportionate, and that legal coercion would be strictly necessary.

S100/CD34-Positive Spindle Cell Mesenchymal Neoplasm Harboring KIAA1549-BRAF Fusion.

ABSTRACT: Mesenchymal neoplasms with oncogenic kinase activity due to genomic alterations in receptor tyrosine kinase genes are a morphologically heterogeneous group with a variable biologic potential. A subset of these neoplasms are characterized by immunophenotypic property of dual S100 protein/CD34 expression, histopathological resemblance to lipofibromatosis or peripheral nerve sheath tumors, and often alterations in neurotrophic tropomyosin-related kinase genes. In this article, we present a case of an S100 protein/CD34-positive spindle cell neoplasm harboring a rare BRAF gene rearrangement (KIAA1549-BRAF fusion) and discuss the clinical, histopathological, and molecular variations associated with such neoplasms.

Parallels, differences and lessons: a comparison of the management of foot-and-mouth disease and COVID-19 using UK 2001/2020 as points of reference.

Foot-and-mouth disease (FMD) is an extremely infectious viral infection of cloven-hoofed animals which is highly challenging to control and can give rise to national animal health crises, especially if there is a lack of pre-existing immunity due to the emergence of new strains or following incursions into disease-free regions. The 2001 FMD epidemic in the UK was on a scale that initially overwhelmed the national veterinary services and was eventually controlled by livestock lockdown and slaughter on an unprecedented scale. In 2020, the rapid emergence of COVID-19 has led to a human pandemic unparalleled in living memory. The enormous logistics of multi-agency control efforts for COVID-19 are reminiscent of the 2001 FMD epidemic in the UK, as are the use of movement restrictions, not normally a feature of human disease control. The UK experience is internationally relevant as few countries have experienced national epidemic crises for both diseases. In this review, we reflect on the experiences and lessons learnt from UK and international responses to FMD and COVID-19 with respect to their management, including the challenge of preclinical viral transmission, threat awareness, early detection, different interpretations of scientific information, lockdown, biosecurity behaviour change, shortage of testing capacity and the choices for eradication versus living with infection. A major lesson is that the similarity of issues and critical resources needed to manage large-scale outbreaks demonstrates that there is benefit to a 'One Health' approach to preparedness, with potential for greater cooperation in planning and the consideration of shared critical resources.

The impact of sex education mandates on teenage pregnancy: International evidence.

To date most studies of the impact of school-based sex education have focused either on specific, local interventions or experiences at a national level. In this paper, we use a new cross-country dataset to explore the extent to which laws on sex education affect teenage pregnancy rates in developed countries. We find some evidence that laws mandating sex education in schools are associated with higher rates of teenage fertility. Parental opt out laws may minimise adverse effects of sex education mandates for younger teens. The estimated effects of mandatory sex education are robust to some but not all of our specifications designed to tease out causality. Taken together, changes in national laws relating to sexual health are unable to explain the significant declines in teenage pregnancy rates, which have been observed in many developed countries in recent years.

Environmental Sampling as a Low-Technology Method for Surveillance of Foot-and-Mouth Disease Virus in an Area of Endemicity.

Environmental sampling enables disease surveillance beyond regular investigation of observed clinical cases, extending data on the circulation of a pathogen in a specific area. Developing straightforward, low-technology methods suitable for use under field conditions is key to the inclusion of such approaches alongside traditional surveillance techniques. Foot-and-mouth disease virus (FMDV) is an economically important livestock pathogen, affecting cloven-hoofed livestock in many countries. Countries with FMDV face severe trade restrictions, and infections can have long-term effects on the productivity of affected animals. Environmental contamination by the virus in excretions and secretions from infected individuals promotes transmission but also presents an opportunity for noninvasive sample collection, facilitating diagnostic and surveillance activities. We present environmental sampling methods that have been tested in the Kathmandu Valley, Nepal, where FMDV is endemic. A total of nine sites were visited and sampled between November 2016 and November 2017. Environmental swabs collected from sites with reported outbreaks of FMD were used to demonstrate successful detection of FMDV RNA from the environment. The development of methods that can reliably detect FMDV RNA in the environment is significant, since this possibility extends the toolbox available for surveillance for this disease. Similar methods have already been deployed in the effort to eradicate polio, and with FMDV, such methods could easily be deployed in the event of an outbreak to provide additional resources for detection that would relieve pressure on veterinary services. The development of low-technology, straightforward surveillance methods such as these can support a robust response to outbreaks.IMPORTANCE Prompt confirmation and diagnosis of disease are key factors in controlling outbreaks. The development of sampling techniques to detect FMDV RNA from the environment will extend the tool kit available for the surveillance of this pathogen. The methods presented in this article broaden surveillance opportunities using accessible techniques. Pairing these methods with existing and novel diagnostic tests will improve the capability for rapid detection of outbreaks and implementation of timely interventions to control outbreaks. In areas of endemicity, these methods can be implemented to extend surveillance beyond the investigation of clinical cases, providing additional data for the assessment of virus circulation in specific areas.

Predicting the Ability of Preclinical Diagnosis To Improve Control of Farm-to-Farm Foot-and-Mouth Disease Transmission in Cattle.

Foot-and-mouth disease (FMD) can cause large disruptive epidemics in livestock. Current eradication measures rely on the rapid clinical detection and removal of infected herds. Here, we evaluated the potential for preclinical diagnosis during reactive surveillance to reduce the risk of between-farm transmission. We used data from transmission experiments in cattle where both samples from individual animals, such as blood, probang samples, and saliva and nasal swabs, and herd-level samples, such as air samples, were taken daily during the course of infection. The sensitivity of each of these sample types for the detection of infected cattle during different phases of the early infection period was quantified. The results were incorporated into a mathematical model for FMD, in a cattle herd, to evaluate the impact of the early detection and culling of an infected herd on the infectious output. The latter was expressed as the between-herd reproduction ratio, Rh , where an effective surveillance approach would lead to a reduction in the Rh value to <1. Applying weekly surveillance, clinical inspection alone was found to be ineffective at blocking transmission. This was in contrast to the impact of weekly random sampling (i.e., using saliva swabs) of at least 10 animals per farm or daily air sampling (housed cattle), both of which were shown to reduce the Rh to <1. In conclusion, preclinical detection during outbreaks has the potential to allow earlier culling of infected herds and thereby reduce transmission and aid the control of epidemics.

The behavioural response of migrating humpback whales to a full seismic airgun array.

Despite concerns on the effects of noise from seismic survey airguns on marine organisms, there remains uncertainty as to the biological significance of any response. This study quantifies and interprets the response of migrating humpback whales (Megaptera novaeangliae) to a 3130 in3 (51.3l) commercial airgun array. We compare the behavioural responses to active trials (array operational; n = 34 whale groups), with responses to control trials (source vessel towing the array while silent; n = 33) and baseline studies of normal behaviour in the absence of the vessel (n = 85). No abnormal behaviours were recorded during the trials. However, in response to the active seismic array and the controls, the whales displayed changes in behaviour. Changes in respiration rate were of a similar magnitude to changes in baseline groups being joined by other animals suggesting any change group energetics was within their behavioural repertoire. However, the reduced progression southwards in response to the active treatments, for some cohorts, was below typical migratory speeds. This response was more likely to occur within 4 km from the array at received levels over 135 dB re 1 µPa2s.

Determining the behavioural dose-response relationship of marine mammals to air gun noise and source proximity.

The effect of various anthropogenic sources of noise (e.g. sonar, seismic surveys) on the behaviour of marine mammals is sometimes quantified as a dose-response relationship, where the probability of an animal behaviourally 'responding' (e.g. avoiding the source) increases with 'dose' (or received level of noise). To do this, however, requires a definition of a 'significant' response (avoidance), which can be difficult to quantify. There is also the potential that the animal 'avoids' not only the source of noise but also the vessel operating the source, complicating the relationship. The proximity of the source is an important variable to consider in the response, yet difficult to account for given that received level and proximity are highly correlated. This study used the behavioural response of humpback whales to noise from two different air gun arrays (20 and 140 cubic inch air gun array) to determine whether a dose-response relationship existed. To do this, a measure of avoidance of the source was developed, and the magnitude (rather than probability) of this response was tested against dose. The proximity to the source, and the vessel itself, was included within the one-analysis model. Humpback whales were more likely to avoid the air gun arrays (but not the controls) within 3 km of the source at levels over 140 re. 1 µPa2 s-1, meaning that both the proximity and the received level were important factors and the relationship between dose (received level) and response is not a simple one.

Addressing Challenges in Studies of Behavioral Responses of Whales to Noise.

Studying the behavioral response of whales to noise presents numerous challenges. In addition to the characteristics of the noise exposure, many factors may affect the response and these must be measured and accounted for in the analysis. An adequate sample size that includes matching controls is crucial if meaningful results are to be obtained. Field work is thus complicated, logistically difficult, and expensive. This paper discusses some of the challenges and how they are being met in a large-scale multiplatform project in which humpback whales are exposed to the noise of seismic air guns.

Distinguishing low frequency mutations from RT-PCR and sequence errors in viral deep sequencing data.

BACKGROUND: RNA viruses have high mutation rates and exist within their hosts as large, complex and heterogeneous populations, comprising a spectrum of related but non-identical genome sequences. Next generation sequencing is revolutionising the study of viral populations by enabling the ultra deep sequencing of their genomes, and the subsequent identification of the full spectrum of variants within the population. Identification of low frequency variants is important for our understanding of mutational dynamics, disease progression, immune pressure, and for the detection of drug resistant or pathogenic mutations. However, the current challenge is to accurately model the errors in the sequence data and distinguish real viral variants, particularly those that exist at low frequency, from errors introduced during sequencing and sample processing, which can both be substantial. RESULTS: We have created a novel set of laboratory control samples that are derived from a plasmid containing a full-length viral genome with extremely limited diversity in the starting population. One sample was sequenced without PCR amplification whilst the other samples were subjected to increasing amounts of RT and PCR amplification prior to ultra-deep sequencing. This enabled the level of error introduced by the RT and PCR processes to be assessed and minimum frequency thresholds to be set for true viral variant identification. We developed a genome-scale computational model of the sample processing and NGS calling process to gain a detailed understanding of the errors at each step, which predicted that RT and PCR errors are more likely to occur at some genomic sites than others. The model can also be used to investigate whether the number of observed mutations at a given site of interest is greater than would be expected from processing errors alone in any NGS data set. After providing basic sample processing information and the site's coverage and quality scores, the model utilises the fitted RT-PCR error distributions to simulate the number of mutations that would be observed from processing errors alone. CONCLUSIONS: These data sets and models provide an effective means of separating true viral mutations from those erroneously introduced during sample processing and sequencing.

Prediction and characterization of novel epitopes of serotype A foot-and-mouth disease viruses circulating in East Africa using site-directed mutagenesis.

Epitopes on the surface of the foot-and-mouth disease virus (FMDV) capsid have been identified by monoclonal antibody (mAb) escape mutant studies leading to the designation of four antigenic sites in serotype A FMDV. Previous work focused on viruses isolated mainly from Asia, Europe and Latin America. In this study we report on the prediction of epitopes in African serotype A FMDVs and testing of selected epitopes using reverse genetics. Twenty-four capsid amino acid residues were predicted to be of antigenic significance by analysing the capsid sequences (n = 56) using in silico methods, and six residues by correlating capsid sequence with serum-virus neutralization data. The predicted residues were distributed on the surface-exposed capsid regions, VP1-VP3. The significance of residue changes at eight of the predicted epitopes was tested by site-directed mutagenesis using a cDNA clone resulting in the generation of 12 mutant viruses involving seven sites. The effect of the amino acid substitutions on the antigenic nature of the virus was assessed by virus neutralization (VN) test. Mutations at four different positions, namely VP1-43, VP1-45, VP2-191 and VP3-132, led to significant reduction in VN titre (P value = 0.05, 0.05, 0.001 and 0.05, respectively). This is the first time, to our knowledge, that the antigenic regions encompassing amino acids VP1-43 to -45 (equivalent to antigenic site 3 in serotype O), VP2-191 and VP3-132 have been predicted as epitopes and evaluated serologically for serotype A FMDVs. This identifies novel capsid epitopes of recently circulating serotype A FMDVs in East Africa.

How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?

OBJECTIVES: Several US states have legalized or decriminalized physician-assisted suicide (PAS) while others are considering permitting PAS. Although it has been suggested that legalization could lead to a reduction in total suicides and to a delay in those suicides that do occur, to date no research has tested whether these effects can be identified in practice. The aim of this study was to fill this gap by examining the association between the legalization of PAS and state-level suicide rates in the United States between 1990 and 2013. METHODS: We used regression analysis to test the change in rates of nonassisted suicides and total suicides (including assisted suicides) before and after the legalization of PAS. RESULTS: Controlling for various socioeconomic factors, unobservable state and year effects, and state-specific linear trends, we found that legalizing PAS was associated with a 6.3% (95% confidence interval 2.70%-9.9%) increase in total suicides (including assisted suicides). This effect was larger in the individuals older than 65 years (14.5%, CI 6.4%-22.7%). Introduction of PAS was neither associated with a reduction in nonassisted suicide rates nor with an increase in the mean age of nonassisted suicide. CONCLUSIONS: Legalizing PAS has been associated with an increased rate of total suicides relative to other states and no decrease in nonassisted suicides. This suggests either that PAS does not inhibit (nor acts as an alternative to) nonassisted suicide, or that it acts in this way in some individuals but is associated with an increased inclination to suicide in other individuals.

Novel antibody binding determinants on the capsid surface of serotype O foot-and-mouth disease virus.

Five neutralizing antigenic sites have been described for serotype O foot-and-mouth disease viruses (FMDV) based on monoclonal antibody (mAb) escape mutant studies. However, a mutant virus selected to escape neutralization of mAb binding at all five sites was previously shown to confer complete cross-protection with the parental virus in guinea pig challenge studies, suggesting that amino acid residues outside the mAb binding sites contribute to antibody-mediated in vivo neutralization of FMDV. Comparison of the ability of bovine antisera to neutralize a panel of serotype O FMDV identified three novel putative sites at VP2-74, VP2-191 and VP3-85, where amino acid substitutions correlated with changes in sero-reactivity. The impact of these positions was tested using site-directed mutagenesis to effect substitutions at critical amino acid residues within an infectious copy of FMDV O1 Kaufbeuren (O1K). Recovered viruses containing additional mutations at VP2-74 and VP2-191 exhibited greater resistance to neutralization with both O1K guinea pig and O BFS bovine antisera than a virus that was engineered to include only mutations at the five known antigenic sites. The changes at VP2-74 and VP3-85 are adjacent to critical amino acids that define antigenic sites 2 and 4, respectively. However VP2-191 (17 Å away from VP2-72), located at the threefold axis and more distant from previously identified antigenic sites, exhibited the most profound effect. These findings extend our knowledge of the surface features of the FMDV capsid known to elicit neutralizing antibodies, and will improve our strategies for vaccine strain selection and rational vaccine design.

Does adding antibiotics to cement reduce the need for early revision in total knee arthroplasty?

BACKGROUND: There is considerable debate about whether antibiotic-loaded bone cement should be used for fixation of TKAs. While antibiotics offer the theoretical benefit of lowering early revision due to infection, they may weaken the cement and thus increase the likelihood of aseptic loosening, perhaps resulting in a higher revision rate. QUESTIONS/PURPOSES: We (1) compared the frequency of early knee revision arthroplasty in patients treated with antibiotic-loaded or non-antibiotic-loaded cement for initial fixation, (2) determined effects of age, sex, comorbidities, and surgeons' antibiotic-loaded cement usage patterns on revision rate, and (3) compared causes of revision (aseptic or septic) between groups. METHODS: Our study sample was taken from the Canadian Joint Replacement Registry and Canada's Hospital Morbidity Database and included cemented TKAs performed between April 1, 2003, and March 31, 2008, including 20,016 TKAs inserted with non-antibiotic-loaded cement and 16,665 inserted with antibiotic-loaded cement. Chi-square test was used to compare the frequency of early revisions between groups. Cox regression modeling was used to determine whether revision rate would change by age, sex, comorbidities, or use of antibiotic-loaded cement. Similar Cox regression modeling was used to compare cause of revision between groups. RESULTS: Two-year revision rates were similar between the groups treated with non-antibiotic-loaded cement and antibiotic-loaded cement (1.40% versus 1.51%, p = 0.41). When controlling for age, sex, comorbidities, diabetes, and surgeons' antibiotic-loaded cement usage patterns, the revision risk likewise was similar between groups. Revision rates for infection were similar between groups; however, there were more revisions for aseptic loosening in the group treated with non-antibiotic-loaded cement (p = 0.02). CONCLUSIONS: The use of antibiotic-loaded cement in TKAs performed for osteoarthritis has no clinically significant effect on reducing revision within 2 years in patients who received perioperative antibiotics. Longer followup and confirmation of these findings with other national registries are warranted.

Bowen disease is not synonymous with intraepidermal squamous cell carcinoma.

The terms 'Bowen disease' and 'intraepidermal squamous cell carcinoma' are sometimes considered synonymous. In this paper we present historical, clinical, histological and molecular evidence that this is incorrect. The term Bowen disease should be reserved for a subset of intraepidermal squamous cell carcinoma with a distinctive and reproducible morphological pattern, described in detail by Bowen in 1912. One other common subset of intraepidermal squamous cell carcinoma represents progression of actinic keratosis. In some cases the separation of these two common patterns of intraepidermal squamous cell carcinoma can be challenging and there are patterns of intraepidermal squamous cell carcinoma which appear to represent other distinct pathways. However, there is emerging biological evidence to support this distinction and reason to suspect that the types of invasive squamous cell carcinoma which arise from these different pathways may show important clinical and biological differences, particularly in the era of targeted and immunomodulatory therapy for advanced disease.

Accumulation of nucleotide substitutions occurring during experimental transmission of foot-and-mouth disease virus.

Analysis of full-genome sequences was previously used to trace the origin and transmission pathways of foot-and-mouth disease virus (FMDV) outbreaks in the UK in 2001 and 2007. Interpretation of these data was sometimes at variance with conventional epidemiological tracing, and was also used to predict the presence of undisclosed infected premises that were later discovered during serological surveillance. Here we report the genome changes associated with sequential passage of a highly BHK-21-cell-adapted (heparan sulphate-binding) strain of FMDV arising from two independent transmission chains in cattle. In vivo virus replication rapidly selected for a wild-type variant with an amino acid substitution at VP3(56). Full-genome sequence analysis clearly demonstrated sequence divergence during parallel passage. The genetic diversity generated over the course of infection and the rate at which these changes became fixed and were transmitted between cattle occurred at a rate sufficient to enable reliable tracing of transmission pathways at the level of the individual animal. However, tracing of transmission pathways was only clear when sequences from epithelial lesions were compared. Sequences derived from oesophageal-pharyngeal scrapings were problematic to interpret, with a varying number of ambiguities suggestive of a more diverse virus population. These findings will help to correctly interpret full-genome sequence analyses to resolve transmission pathways within future FMDV epidemics.

Evolution of foot-and-mouth disease virus intra-sample sequence diversity during serial transmission in bovine hosts.

RNA virus populations within samples are highly heterogeneous, containing a large number of minority sequence variants which can potentially be transmitted to other susceptible hosts. Consequently, consensus genome sequences provide an incomplete picture of the within- and between-host viral evolutionary dynamics during transmission. Foot-and-mouth disease virus (FMDV) is an RNA virus that can spread from primary sites of replication, via the systemic circulation, to found distinct sites of local infection at epithelial surfaces. Viral evolution in these different tissues occurs independently, each of them potentially providing a source of virus to seed subsequent transmission events. This study employed the Illumina Genome Analyzer platform to sequence 18 FMDV samples collected from a chain of sequentially infected cattle. These data generated snap-shots of the evolving viral population structures within different animals and tissues. Analyses of the mutation spectra revealed polymorphisms at frequencies >0.5% at between 21 and 146 sites across the genome for these samples, while 13 sites acquired mutations in excess of consensus frequency (50%). Analysis of polymorphism frequency revealed that a number of minority variants were transmitted during host-to-host infection events, while the size of the intra-host founder populations appeared to be smaller. These data indicate that viral population complexity is influenced by small intra-host bottlenecks and relatively large inter-host bottlenecks. The dynamics of minority variants are consistent with the actions of genetic drift rather than strong selection. These results provide novel insights into the evolution of FMDV that can be applied to reconstruct both intra- and inter-host transmission routes.

A rare case: synchronous ipsilateral breast implant-associated anaplastic large cell lymphoma and invasive ductal carcinoma.

A 78-year-old female with a history of cosmetic breast implants presented with unilateral breast enlargement and was subsequently diagnosed with stage IA breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) as well as stage IB ipsilateral synchronous invasive ductal carcinoma (IDC). Her assessment included bilateral breast ultrasounds,mammograms and MRIs with right-sided fine needle aspiration of peri-implant fluid, core biopsy of right breast mass and a whole-body positron emission tomography scan. She was surgically treated with bilateral capsulectomy, implant removal and mastectomy. No adjuvant treatment was required for the BIA-ALCL. The IDC required adjuvant chemotherapy, radiotherapy and endocrine therapy. This rare case highlights the paramount importance of thorough evaluation of suspected BIA-ALCL patients for synchronous breast pathologies. We conclude with a concise summary of the salient points on evaluation and management of BIA-ALCL for surgeons.