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Background: Dysphagia places a substantial burden on the critically ill, affecting 12%–84% of this cohort, and is independently associated with worse outcomes. Pharyngeal electrical stimulation (PES-treatment) is a novel dysphagia therapy with an emerging evidence base. This retrospective observational study describes our dysphagia service and reports the use of PES-treatment as a standard of care in recovering critically ill patients at a single-site tertiary UK hospital.Methods: Patients admitted to Acute or Cardio-Thoracic adult intensive care units between 1st July 2017 and 30th June 2022 were routinely referred to Speech and Language Therapy (SLT) following tracheostomy, or suspected dysphonia/dysphagia. Clinical assessments and direct laryngeal visualisation using Fibreoptic Evaluation of Swallowing (FEES) were performed. Severe dysphagia was defined as Penetration-Aspiration Score of ⩾6 and patients were offered PES-treatment when staffing allowed.Results: Of 289 patients with severe dysphagia, 19 underwent a course of PES-treatment with the remaining patients receiving standard care. PES-treatment patients were significantly less likely to remain nil-by-mouth (11.1% vs 62.5%, Chi2p< 0.001) or to have an enteral feeding tube in situ at discharge from critical care (27.8% vs 62.5%, p= 0.006) than those receiving standard dysphagia care. Both groups demonstrated an improvement in Penetration-Aspiration Score at repeat FEES: PES-treatment mean difference −2.0 (p= 0.003); non-PES-treatment −1.68 (p< 0.001); (61% PES-treatment improved vs 40% non-PES-treatment, p= 0.09).Conclusion: Our observations suggest that PES may be effective in the general critical care population. PES may offer new treatment options for patients and healthcare staff managing severe dysphagia and its significant consequences.

Non-ischemic priapism (NiP) is painless partial tumescence caused by genital trauma and the formation of intracorporal arterio-venous fistula. This is a retrospective study of 25 men with NiP and reports the long-term erectile function and colour doppler ultrasound (CDUS) findings after treatment for NiP. Unstimulated CDUS was performed at diagnosis, 1 week and at last follow-up after treatment. CDUS traces were analysed: peak systolic velocity (PSV), end diastolic velocity (EDV), resistive index (RI) and mean velocity (MV) were calculated. Erectile function was assessed using the IIEF-EF questionnaire. At the last follow-up (median 24 months), 16 men had normal erectile function (64%): median IIEF-EF score 29 (IQR 28.5–30; σ22.78) and nine had erectile dysfunction (36%): median IIEF-EF score 17 (IQR 14–22; σ233.6). MV and EDV were statistically higher in those patients with erectile dysfunction at last follow-up compared to patients with normal erectile function: median MV 5.3 cm/s (IQR 2.4–10.5 cm/s; σ234) vs 2.95 cm/s (IQR 1.03-3.95; σ23.4) p< 0.002 and median EDV 4.0 cm/s (IQR 1.5–8.0; σ214.7) vs 0 cm/s (IQR 0–1.75; σ22.21) p< 0.004. Erectile dysfunction was observed in 36% of men treated for NiP and was associated with abnormal low resistance resting CDUS waveforms. Further investigation for persistent arteriovenous fistulation should be considered in these patients.

Imaging has a specific role in the diagnosis and management of priapism. The primary imaging modality is ultrasound with colour Doppler (CDUS) which can accurately assess the hemodynamics of the cavernosal arteries. This is particularly useful in equivocal cases and can help differentiate ischemic from non-ischemic priapism as well as confirm the presence and location of arterio-venous fistulae post penile trauma. Furthermore, CDUS is invaluable in the post treatment follow up of non-ischemic priapism. Contrast enhanced magnetic resonance imaging (MRI) can demonstrate the extent of cavernosal necrosis in ischemic priapism and in conjunction with computer tomography (CT) has an important role in excluding underlying malignancy. MRI and CT angiography are used to evaluate pudendal arterial anatomy, which can be extremely variable and aids in the management of non-ischemic priapism. In selected cases of non-ischemic priapism, catheter angiography and transcatheter embolization of arteriovenous fistulae is an effective treatment. This review will examine the specific roles of different imaging modalities in the subtypes of priapism as well as highlight some of the pitfalls encountered in imaging.

Recent years have seen a trend towards change in glaucoma treatment. In addition to classic trabeculectomy, implant surgeries such as those based on the Baerveldt, Ahmed and Molteno devices are increasingly performed as a primary procedure. This is doubtless partly due to the fact that surgeons have become more comfortable with the use of tube shunts and their postoperative management. The aim of this article is to present the currently available evidence on glaucoma surgery in a succinct format, to enable the best possible decisions to be made for patients.

Significance Statement Granulomatosis with polyangitis (GPA) is a systemic necrotizing vasculitis comprising of inflammation of small and medium-sized vessels.1It typically presents with involvement of the upper and lower airways as well as the kidneys. If left untreated, end-organ damage may occur. Hematological investigations typically demonstrate the presence of antinuclear cytoplasmic antibodies (ANCA).2Here, we discuss an unusual presentation of ANCA negative GPA, presenting initially with nasal symptoms.

ABSTRACTWith a long history as a vehicle for preserving perishable fillings against spoilage, pie was imagined as both a lavish banqueting centerpiece and an edible symbol of globalization in the seventeenth and eighteenth century British and early American worlds. Filled with expensive and difficult-to-obtain ingredients, and frequently sent over long distances in a culture of performative gift-exchange, pies were complex and multivalent objects. By examining the pie’s reputation as a means of preserving food alongside its widespread – but now largely forgotten – cultural association with death and dying, we suggest that for elite consumers, these pastry “coffins” could fulfill a similar function to memento mori: a reminder of the impermanence of organic matter and the inevitability of death and decomposition. Taking pie, an edible and ephemeral food, as a subject of material-cultural analysis, we can open unexpected avenues for understanding some of the emotions evoked by global consumption.

BackgroundWe aimed to create a multidisciplinary consensus clinical guideline for best practice in the diagnosis, investigation and management of spontaneous intracranial hypotension (SIH) due to cerebrospinal fluid leak based on current evidence and consensus from a multidisciplinary specialist interest group (SIG).MethodsA 29-member SIG was established, with members from neurology, neuroradiology, anaesthetics, neurosurgery and patient representatives. The scope and purpose of the guideline were agreed by the SIG by consensus. The SIG then developed guideline statements for a series of question topics using a modified Delphi process. This process was supported by a systematic literature review, surveys of patients and healthcare professionals and review by several international experts on SIH.ResultsSIH and its differential diagnoses should be considered in any patient presenting with orthostatic headache. First-line imaging should be MRI of the brain with contrast and the whole spine. First-line treatment is non-targeted epidural blood patch (EBP), which should be performed as early as possible. We provide criteria for performing myelography depending on the spine MRI result and response to EBP, and we outline principles of treatments. Recommendations for conservative management, symptomatic treatment of headache and management of complications of SIH are also provided.ConclusionsThis multidisciplinary consensus clinical guideline has the potential to increase awareness of SIH among healthcare professionals, produce greater consistency in care, improve diagnostic accuracy, promote effective investigations and treatments and reduce disability attributable to SIH.

AbstractThis article explores the early modern understanding of the gut-mind relationship through a study of the beliefs and practices surrounding the hellebore plant in seventeenth-century England. Hellebore has been strongly associated with mental illness for most of recorded European history, and it is only during the past two centuries that it has lost this association. Taking a phenomenological approach, I demonstrate that the study of this specific plant, its representations, and its practices is significant not just to plant folklorists and medical historians but also to wider histories of culture, religion, emotion, and the body. The use of hellebore as a treatment for disorders of the mind reveals a fully embodied view of emotion in which the gut played a key role in shaping subjective experience. It also reflects a potently negative understanding of emotion as excremental matter, as something inherently impure, dangerous, and evil, warranting a violent remedy that was as punitive as it was therapeutic. By analyzing medical sources—herbals, pharmacopoeias, practitioners’ casebooks, and domestic receipt books—alongside devotional literature and religious polemic, I show that hellebore's symbolic importance was inseparable from its practical use as a treatment for mental illness, which depended upon an understanding of emotion and religious identity that accorded vital significance to the relationship between belly and brain.

Men with Stuttering Priapism (SP) and sleep-related painful erections (SRPE) experience bothersome nocturnal painful erections resulting in poor sleep. The aim of this study is to observe common features and differences between men with SP and SRPE based on polysomnography, nocturnal penile tumescence (NPT), and penile doppler ultrasound (PDU). This is a prospective cohort study of 20 participants divided into two groups (Group 1 = SP [n= 12]; Group 2 = SRPE [n= 8]) with bothersome painful nocturnal erections. All participants were referred to the sleep disorder clinic to be assessed and consented for overnight polysomnography with simultaneous NPT recording and to complete validated sleep, sexual dysfunction and health-related quality of life questionnaires. Unstimulated PDU was also performed. Abnormal Polysomnographic findings (reduced sleep efficiency, total sleep time, and awake after sleep onset) were identified in both groups suggesting poor sleep. Men with SP had significantly longer erections (60.0 vs 18.5; p= 0.002) and took longer to detumesce once awake (25.7 vs 5.4 min; p= 0.001) than men with SRPE. They also had significantly higher peak systolic and end diastolic velocities on unstimulated PDU with an abnormal low resistance waveform identified. No sleep pathology was identified in men with SP. This implies a local (penile) etiology in men with SP. Men with SRPE had a normal resting PDU and abnormal sleep architecture with REM awakenings and significantly more Periodic limb movements (p= 0.04) than men with SP suggesting a central (sleep-related) cause in men with SRPE. Sexual dysfunction and poor HR-QoL was identified on validated questionnaires in both groups. SP and SRPE are rare entities that share similar symptoms (painful nocturnal erections and poor sleep) but dissimilar features of nocturnal erection onset, duration and resolution with different polysomnographic features which may allude to a different pathophysiology.

Polycythaemia vera (PV) is a clonal proliferative disorder of the bone marrow characterised by autonomous haematopoiesis, which results in a panmyelosis in the peripheral blood. It is typically characterised by an acquired mutation in JAK-2 V617F. Progression to myelofibrosis (MF), characterised by worsening cytopenias and the development of constitutional symptoms, is seen in up to 10% of cases. Extramedullary haematopoiesis (EMH) in the spleen is a common finding in myelofibrotic transformation, but elsewhere in the body it is extremely unusual. We report the case of a 69-year-old male whose PV progressed to secondary MF and who presented with compression of the thoracic spinal cord directly as a result of EMH. Cytogenetic and molecular findings in the bone marrow were in keeping with evolving myeloid disease. He was managed by surgical laminectomy with an excellent outcome. Extramedullary haematopoiesis may be seen in both PV and on transformation to MF. This very rare complication should be borne in mind when managing patients with myeloproliferative disorders.

Introduction Splenogonadal fusion is a rare developmental disorder that results in a gonadal or paragonadal mass due to the close proximity of the developing spleen and gonad.Case report We describe a case of splenogonadal fusion presenting as a paratesticular mass in a 25-year-old male. This was ultimately diagnosed on surgical biopsy.Discussion Splenogonadal fusion is a rare abnormality but can be managed conservatively. The sonographic features and the differential diagnosis are highlighted.Conclusion Through this case, we highlight the clinical and sonographic features of splenogonadal fusion. Awareness amongst ultrasound practitioners is important, given that it can be managed conservatively, and means of a non-invasive diagnosis are highlighted.

In case of small testicular masses, excising the whole testicle may represent overtreatment affecting fertility and hormonal function, since most lesions under 2 cm are not cancerous. Management of small lesions is unclear, and in this study, an expert panel has developed consensus recommendations.

Neurodegeneration has been reported in young animals after exposure to all commonly used general anesthetic agents. The brain may be particularly vulnerable to anesthetic toxicity during peak synaptogenesis (in gestation and infancy). Human studies of long-term neurodevelopmental outcome following general anesthesia in early childhood report contradictory findings. This review assesses the strengths and deficiencies in human research methodologies to inform future studies. We identified 76 studies, published between 1990 and 2017, of long-term neurodevelopmental outcome following early childhood or in utero general anesthesia exposure: 49 retrospective, 9 ambidirectional, 17 prospective cohort studies, and 1 randomized controlled trial. Forty-nine studies were explicitly concerned with anesthetic-induced neurotoxicity. Full texts were appraised for methodological challenges and possible solutions. Major challenges identified included delineating effects of anesthesia from surgery, defining the timing and duration of exposure, selection of a surgical cohort and intervention, addressing multiple confounding life course factors, detecting modest neurotoxic effects with small sample sizes (median, 131 children; interquartile range, 50–372), selection of sensitive neurodevelopmental outcomes at appropriate ages for different developmental domains, insufficient length of follow-up (median age, 6 years; interquartile range, 2–12 years), and sample attrition. We discuss potential solutions to these challenges. Further adequately powered, multicenter, prospective randomized controlled trials of anesthetic-induced neurotoxicity in children are required. However, we believe that the inherent methodological challenges of studying anesthetic-induced neurotoxicity necessitate the parallel use of well-designed observational cohort studies.

Objective: To explore self-inflicted retinal burns from laser pointers in children. Methods: Literature review of laser pointer retinal injuries in childhood and online survey of UK Consultant Ophthalmologists. A cohort of local children with self-inflicted injury is described. The matter is topical. We review progress in recent legislation and policy change in the UK. Results: Four of 77 case reports of laser burns in childhood analysed reported psychological or behavioural issues. Three of four children in our cohort had such issues. Delay in diagnosis occurred in two of our patients. Structural retinal damage persisted for over 12 months in all four children (seven eyes). Our survey of UK ophthalmologists found 159 cases of injury (85% male), 80% under 20 years of age. The majority of the laser pointers were purchased online. Many patients (36%) suffered moderate vision loss (6/18 to 6/60 Snellen), while 17% (at least 11 patients) suffered severe vision loss (&lt;6/60 Snellen). Conclusion: We highlight the risk of macular damage and vision loss from handheld lasers specifically in children with behavioural, learning or mental health issues. The diagnosis may be difficult or delayed in such children. In children with uncertain macular changes, ophthalmologists should explore the history for possible instances of exposure to handheld lasers pointers. Regulatory authorities and manufacturers of handheld lasers need to be aware of the risk to children. Furthermore, there is a need to better inform parents, carers and teachers of the risk of ocular self-injury from such lasers pointers.

To define the safety profile of trainee trabeculectomy surgery in the United Kingdom. Surgical exposure for trainees in England is limited due to service requirements, the European working time directive constraints and increasing sub-specialisation of glaucoma surgery. Limited knowledge exists on the outcomes of supervised glaucoma surgery. The aim is to determine the safety of supervised trabeculectomy surgery performed by trainee ophthalmologists. Retrospective case note review of all patients that had trabeculectomy surgery with MMC by consultant and trainee surgeons across multiple UK centres. All eyes have 2-year follow up. Success was determined using WGA guidelines. Two-tailed pvalues were obtained using Fisher’s exact test to ascertain statistical significance between groups. Main outcome measures: intraocular pressure, visual acuity, success and failure rates. 324 eyes were reviewed. 211 (66.4%) cases were performed by glaucoma consultants, 107(33.6%) by trainee ophthalmologists. The majority of eyes in each group were undergoing surgery for POAG. Post-operative IOP control showed no significant difference between consultant and trainee groups at year 1 and year 2. Success rates showed no significant difference between consultant and trainee cases. Failure rates at year 1 showed a significant difference between the two groups. No significant difference was seen at year 2. The trainee group had significantly more complications, when compared with the consultant group. Snellen visual acuity loss was not statistically significant between the two groups at the 2 year time point. The outcomes of supervised trainee trabeculectomy compare favourably with consultant cases after 2 year follow up. Trainee cases had higher complication rates than consultant cases. Bleb leaks are a common complication of trainee cases, where closer supervision may be required. There is potential for surgical simulation to help increase the success of such cases. These findings may encourage trainee participation in glaucoma surgery.

PurposeTo report the efficacy, safety profile, and postoperative management of XEN45 implant at 12-month follow-up.Patients and methodsThis was a retrospective, non-randomised interventional case series involving patients who underwent XEN45 implantation by a single, experienced glaucoma specialist in a tertiary centre. Primary outcome measures were the intraocular pressure (IOP) and the number of medications at 1-year follow-up visit. Two IOP criteria were chosen to measure success: IOP ≤21 mm Hg and ≥20% reduction from baseline (criteria one); and IOP ≤15 mm Hg and ≥30% reduction from baseline (criteria two).ResultsAll 39 eyes completed 1-year follow-up. The mean preoperative IOP was 24.9±7.8 mm Hg on three drops, which reduced to 14.5±3.4 mm Hg at month 12 (P<0.005) on 0.7 drops (P<0.005). On the basis of criteria one, the cumulative probability of success at 1 year was 87.0% without medication and 92.0% with medication. On the basis of criteria two, cumulative probability of success was 62.0% without medication and 64.0% with medication. Bleb intervention with a median of 2 (range 1–4) was required for 51.3% of eyes. Implant was obstructed by iris tissue in three eyes (7.7%); one eye (2.6%) developed hyphaema; eight eyes (20.5%) had numerical hypotony (IOP≤5 mm Hg) at day 1, of which all spontaneously resolved by week 4 apart from one eye.ConclusionsThe XEN45 implant proved to be an effective treatment with a good safety profile at 1-year follow-up period. The high rate of postoperative bleb intervention does not make XEN45 a ‘fit-and-forget’ procedure and therefore the procedure should ideally be performed by surgeons experienced in bleb management.

In this paper we investigate the place of origin of the change from Jespersen’s Cycle stage II – bipartite ne+ not– to stage III, notalone. We use the LAEME corpus to investigate the dialectal distribution in more detail, finding that the change must have begun in Northern and Eastern England. A strong effect of region and time period can be clearly observed, with certain linguistic factors also playing a role. We attribute the early onset of the change to contact with Scandinavian: North Germanic is known to have undergone Jespersen’s Cycle earlier in its history, and the geographical distribution of early English stage III fits neatly with the earlier boundaries of the Danelaw.

PurposeTo investigate the frequencies, trends, and in vitro drug susceptibilities of the causative pathogens in microbial keratitis in Manchester Royal Eye Hospital.Patients and methodsCorneal scrape results recorded by the microbiology service between 2004 and 2015 were extracted from an established database. A total of 4229 corneal scrape specimens were identified from an established database. First-line antibiotic treatment in our centre during the study period was ofloxacin and second line was cefuroxime and gentamicin.ResultsMean age was 45.9±21.0. A total of 1379 samples (32.6%) were culture positive. One hundred forty-eight (10.7%) specimens cultured multiple organisms. Of the 1539 organisms identified, 63.3% were Gram-positive bacteria, 27.3% Gram-negative bacteria, 7.1% fungi, and 2.3% Acanthamoebae. A decreasing trend in Gram-positive isolates was found together with a stable trend in Gram negatives and an increasing trend in Acanthamoeba and fungi. There appeared to be a significant increasing trend of Moraxella infection (P=0.001). In all, 83.1 and 90.8% of Gram-positive and -negative isolates tested were susceptible to ofloxacin, respectively. Cefuroxime covered 86.6% of Gram-positive and 61.4% of Gram-negative isolates, whereas gentamicin covered 88.8 and 96.5% of Gram-positive and -negative isolates, respectively.ConclusionWe found a change in the type of Gram-negative organisms isolated over time, with the Moraxella species on the rise. Reassuringly, no significant increase in resistance was observed in vitro for any of the commonly used antibiotics. Ofloxacin remains a good first-line antibiotic treatment but duo-therapy does have broader coverage and should be considered in non-responsive cases.

ABSTRACTInfection with Burkholderia pseudomalleicauses melioidosis, a disease with a high mortality rate (20% in Australia and 40% in Southeast Asia). Neurological melioidosis is particularly prevalent in northern Australian patients and involves brain stem infection, which can progress to the spinal cord; however, the route by which the bacteria invade the central nervous system (CNS) is unknown. We have previously demonstrated that B. pseudomalleican infect the olfactory and trigeminal nerves within the nasal cavity following intranasal inoculation. As the trigeminal nerve projects into the brain stem, we investigated whether the bacteria could continue along this nerve to penetrate the CNS. After intranasal inoculation of mice, B. pseudomalleicaused low-level localized infection within the nasal cavity epithelium, prior to invasion of the trigeminal nerve in small numbers. B. pseudomalleirapidly invaded the trigeminal nerve and crossed the astrocytic barrier to enter the brain stem within 24 h and then rapidly progressed over 2,000 μm into the spinal cord. To rule out that the bacteria used a hematogenous route, we used a capsule-deficient mutant of B. pseudomalleithat does not survive in the blood and found that it also entered the CNS via the trigeminal nerve. This suggests that the primary route of entry is via the nerves that innervate the nasal cavity. We found that actin-mediated motility could facilitate initial infection of the olfactory epithelium. Thus, we have demonstrated that B. pseudomalleican rapidly infect the brain and spinal cord via the trigeminal nerve branches that innervate the nasal cavity.

Two different types of test were used to relate the strength of the branch attachments to standard methods of testing sawn timber. Using the British Standard method for testing sawn timber, it was demonstrated that the strain orientation and morphology of the aspect ratio, crotch angle and moment are linked within the mechanical properties of the branch attachments. Comparison of the results of such testing with intact branches, using a different method, shows a degree of correspondence between these two approaches, and this may provide insight into the internal workings of branch attachments.

In Ethiopia, most chicken disease outbreaks and mortalities are attributed to a respiratory syndrome known as “fengil” with variable clinical signs and undefined etiology. The main goal of this study was to determine whether key respiratory pathogens that could contribute to the fengil syndrome circulate in Ethiopia. Specifically, we aimed to determine the seroprevalence of infectious laryngotracheitis virus (ILTV), infectious bronchitis virus (IBV), Newcastle disease virus (NDV), Mycoplasma gallisepticum(Mg), and avian metapneumovirus (aMPV). A cross-sectional survey was conducted in 158 scavenging and 42 small and medium-scale intensive chicken holdings in the East, West and North Shewa Zones of central Ethiopia. Blood from 495 chickens was collected and serological tests were used to determine exposure to these pathogens. Vaccination against NDV was the only immunization practiced with a significantly higher vaccination rate in the intensive than the scavenging system. Serological evidence of a high level of exposure to all pathogens was detected, including the first report on the seroprevalence of aMPV, ILTV, and IBV in the East Shewa Zone. The chicken and holding seroprevalence rates were respectively 91% and 94% for IBV, 34% and 57% for aMPV, 47% and 66% for Mg, 27% and 51% for ILTV and in unvaccinated flocks, 39% and 53% for NDV. These pathogens could contribute to the fengil syndrome, commonly ascribed to NDV. The seroprevalence of aMPV and ILTV was higher in chickens under the scavenging system. Exposure to multiple pathogens was common, with more than 50% of chickens positive for three or more pathogens in the scavenging system. This was reflected in significant positive associations between seropositivity to ILTV, Mg, ILTV, and IBV. The role of these pathogens in the causation of respiratory disease in the field requires further investigation.

A 17-year-old female patient was admitted for an elective mini laparotomy and cystectomy of the right ovary for the treatment of chronic supra-pubic abdominal pain. The procedure went without complication and she was discharged the next day. She was re-admitted a month later as an acute case with wound dehiscence. HIV serology, thyroid function, immunoglobulin, protein electrophoresis and electrolyte levels were all normal. There were no obvious signs of infection and the bacterial swabs failed to culture an organism. Despite conservative measures with regular dressing, oral antibiotics and input from the tissue viability team the wound failed to epithelialise. The wound was debrided and re-sutured a total of three times and the patient received 24 days of intravenous antibiotics. After input from various teams a diagnosis of Ehlers-Danlos syndrome was made, allowing for appropriate management and wound healing.

ABSTRACTInfluenza viruses remain a major threat to global health due to their ability to undergo change through antigenic drift and antigenic shift. We postulated that avian IgY antibodies represent a low-cost, effective, and well-tolerated approach that can easily be scaled up to produce enormous quantities of protective antibodies. These IgY antibodies can be administered passively in humans (orally and intranasally) and can be used quickly and safely to help in the fight against an influenza pandemic. In this study, we raised IgY antibodies against H1N1, H3N2, and H5N1 influenza viruses. We demonstrated that, using whole inactivated viruses alone and in combination to immunize hens, we were able to induce a high level of anti-influenza virus IgY in the sera and eggs, which lasted for at least 2 months after two immunizations. Furthermore, we found that by use of in vitroassays to test for the ability of IgY to inhibit hemagglutination (HI test) and virus infectivity (serum neutralization test), IgYs inhibited the homologous as well as in some cases heterologous clades and strains of viruses. Using an in vivomouse model system, we found that, when administered intranasally 1 h prior to infection, IgY to H5N1 protected 100% of the mice against lethal challenge with H5N1. Of particular interest was the finding that IgY to H5N1 cross-protected against A/Puerto Rico/8/34 (H1N1) both in vitroand in vivo. Based on our results, we conclude that anti-influenza virus IgY can be used to help prevent influenza virus infection.

Coastal flood risk is a function of the probability of coastal flooding and the consequential damage. Scenarios of potential changes in coastal flood risk due to changes in climate, society and the economy over the twenty-first century have been analysed using a national-scale quantified flood risk analysis methodology. If it is assumed that there will be no adaptation to increasing coastal flood risk, the expected annual damage in England and Wales due to coastal flooding is predicted to increase from the current £0.5 billion to between £1.0 and £13.5 billion, depending on the scenario of climate and socio-economic change. The proportion of national flood risk that is attributable to coastal flooding is projected to increase from roughly 50% to between 60 and 70%. Scenarios of adaptation to increasing risk, by construction of coastal dikes or retreat from coastal floodplains, are analysed. These adaptations are shown to be able to reduce coastal flood risk to between £0.2 and £0.8 billion. The capital cost of the associated coastal engineering works is estimated to be between £12 and £40 billion. Non-structural measures to reduce risk can make a major contribution to reducing the cost and environmental impact of engineering measures.