If Not NOW, When? A People-Focused Change Model to Improve Patient Flow.

Through an ambitious change management initiative titled "No One Waits (NOW)," Bluewater Health leaders enlisted staff to take ownership of reducing wait times by identifying barriers to transitions within the hospital and to the community. The approach shifted the hospital's culture to overcome those impediments and succeed in reducing wait times dramatically, including compared with peers. Meanwhile, overall patient experience ratings improved and staff trust increased. These changes have been maintained over several years and have resulted in better management of patient volumes during the COVID-19 pandemic and the current health human resources crisis.

Brunner's gland hyperplasia in a geriatric chimpanzee (Pan troglodytes), an infrequently reported lesion.

Benign duodenal tumours have very rarely been reported in captive non-human primates and are also rare in human beings. Brunner's gland hyperplasia has not been fully described in a non-human primate. Here, we report Brunner's gland hyperplasia in a geriatric chimpanzee, which was an incidental finding during post-mortem examination.

Lumpy Skin Disease Is Characterized by Severe Multifocal Dermatitis With Necrotizing Fibrinoid Vasculitis Following Experimental Infection.

Lumpy skin disease is a high-consequence disease in cattle caused by infection with the poxvirus lumpy skin disease virus (LSDV). The virus is endemic in most countries in Africa and an emerging threat to cattle populations in Europe and Asia. As LSDV spreads into new regions, it is important that signs of disease are recognized promptly by animal caregivers. This study describes the gross, microscopic, and ultrastructural changes that occur over time in cattle experimentally challenged with LSDV. Four calves were inoculated with wildtype LSDV and monitored for 19 to 21 days. At 7 days after inoculation, 2 of the 4 cattle developed multifocal cutaneous nodules characteristic of LSD. Some lesions displayed a targetoid appearance. Histologically, intercellular and intracellular edema was present in the epidermis of some nodules. Occasional intracytoplasmic inclusion bodies were identified in keratinocytes. More severe and consistent changes were present in the dermis, with marked histiocytic inflammation and necrotizing fibrinoid vasculitis of dermal vessels, particularly the deep dermal plexus. Chronic lesions consisted of full-thickness necrosis of the dermis and epidermis. Lesions in other body organs were not a major feature of LSD in this study, highlighting the strong cutaneous tropism of this virus. Immunohistochemistry and electron microscopy identified LSDV-infected histiocytes and fibroblasts in the skin nodules of affected cattle. This study highlights the noteworthy lesions of LSDV and how they develop over time.

MANDIBULAR SQUAMOUS CELL CARCINOMA IN A ROCK HYRAX ( PROCAVIA CAPENSIS).

A 9-yr-old, entire female captive rock hyrax ( Procavia capensis) was presented with a 1-wk history of sialorrhea. On clinical examination, a mass was identified, encompassing the rostral mandible and intermandibular area, with associated mucosal ulceration, marked gingival recession, and loosening or loss of adjacent teeth. Skull radiography and cytology of fine-needle aspirates of the mass were suggestive of squamous cell carcinoma. Based on a suspected poor prognosis, the animal was humanely euthanized. Postmortem histological examination of samples confirmed a diagnosis of oral squamous cell carcinoma with invasion of mandibular bone. Neoplasia is uncommonly reported in hyraxes, which has led to the assumption that they may share mechanisms of cancer resistance with elephants, their closest extant relatives. This is the first report of squamous cell carcinoma in this species.

SUSPECTED HYPOVITAMINOSIS A-ASSOCIATED SALT GLAND ADENITIS IN NORTHERN ROCKHOPPER PENGUINS ( EUDYPTES MOSELEYI).

Supraorbital salt-excreting glands are present in at least 10 avian orders and are largest in marine species, including penguins. Diseases of the avian salt gland have been described infrequently. From September 2015, five captive northern rockhopper penguins ( Eudyptes moseleyi) were presented over a 6-wk period for unilateral or bilateral supraorbital swellings. In September 2016, two cases recurred and two additional cases were identified. Histopathology demonstrated salt gland adenitis with extensive squamous metaplasia. Blood plasma testing demonstrated marked vitamin A and E deficiencies within the colony. Prolonged frozen storage of feed-fish was implicated as a cause of vitamin depletion; reducing storage times and addition of dietary supplementation prevented recurrence.

Compared to sucrose, previous consumption of fructose and glucose monosaccharides reduces survival and fitness of female mice.

BACKGROUND: Intake of added sugar has been shown to correlate with many human metabolic diseases, and rodent models have characterized numerous aspects of the resulting disease phenotypes. However, there is a controversy about whether differential health effects occur because of the consumption of either of the two common types of added sugar-high-fructose corn syrup (fructose and glucose monosaccharides; F/G) or table sugar (sucrose, a fructose and glucose disaccharide). OBJECTIVES: We tested the equivalence of sucrose- vs. F/G-containing diets on mouse (Mus musculus) longevity, reproductive success, and social dominance. METHODS: We fed wild-derived mice, outbred mice descended from wild-caught ancestors, a diet in which 25% of the calories came from either an equal ratio of F/G or an isocaloric amount of sucrose (both diets had 63% of total calories as carbohydrates). Exposure lasted 40 wk, starting at weaning (21 d of age), and then mice (104 females and 56 males) were released into organismal performances assays-seminatural enclosures where mice competed for territories, resources, and mates for 32 wk. Within enclosures all mice consumed the F/G diet. RESULTS: Females initially fed the F/G diet experienced a mortality rate 1.9 times the rate (P = 0.012) and produced 26.4% fewer offspring than females initially fed sucrose (P = 0.001). This reproductive deficiency was present before mortality differences, suggesting the F/G diet was causing physiologic performance deficits prior to mortality. No differential patterns in survival, reproduction, or social dominance were observed in males, indicating a sex-specific outcome of exposure. CONCLUSION: This study provides experimental evidence that the consumption of human-relevant levels of F/G is more deleterious than an isocaloric amount of sucrose for key organism-level health measures in female mice.

Equine grass sickness is associated with major abnormalities in the ultrastructure of skeletal neuromuscular junctions.

BACKGROUND: Equine grass sickness (EGS) is a frequently fatal multisystem neuropathy of equids. The aetiology is unknown; proposed causes include toxicoinfection with Clostridium botulinum and a mycotoxicosis. The effect of EGS on the organisation and structural integrity of the skeletal neuromuscular junction (NMJ), the target of botulinum neurotoxins (BoNTs), is unknown. OBJECTIVES: To compare the organisation and structural integrity of skeletal NMJs from EGS horses, control horses and one horse with a presumptive diagnosis of botulism. STUDY DESIGN: Blinded, retrospective case control. METHODS: NMJs in samples of diaphragm or intercostal muscle from six EGS horses, three control horses and one equine botulism case were compared using electron microscopy, morphometry and confocal light microscopy. RESULTS: A significantly higher percentage of EGS NMJs had abnormal morphology (EGS 72.2%, 95% CI 55.6-84.4; Controls 6.9%, 1.7-23.8; OR 35.1, 8.47-244.8; p < 0.001). EGS NMJs had a significantly lower mean volume fraction occupied by synaptic vesicles (SVs) (EGS 18.7%, 12.6-28.0; Controls 36.3%, 20.8-63.4; p = 0.024). EGS NMJs had evidence of accelerated SV exocytosis and SV depletion, accumulation of neurofilament-like material in terminal boutons and/or bouton degeneration. NMJs from the botulism horse had dense packing of SVs towards the presynaptic membrane active zone, consistent with BoNT intoxication, but had absence of the abnormalities identified in EGS NMJs. MAIN LIMITATIONS: Group sizes were limited by difficulties obtaining suitably processed samples. Ages of control and EGS horses differed. Botulism was diagnosed based on clinical and post mortem findings. CONCLUSIONS: EGS is associated with major changes in skeletal NMJ ultrastructure that are inconsistent with the effects of BoNTs. SV depletion may reflect increased exocytosis coupled with reduced repopulation of SVs via anterograde axonal transport and endocytosis, consistent with the action of an excitatory presynaptic toxin and/or neurotransmitter reuptake inhibitor. Skeletal NMJs represent a previously unrecognised target for the toxin that causes EGS.

Marek's Disease in an Indian Peafowl (Pavo cristatus) with Clinical Ocular Disease and Paraparesis.

Marek's disease (MD) is caused by virulent strains of Gallid alphaherpesvirus type 2 (MD virus serotype 1; MDV 1) and frequently causes a lymphoproliferative disorder in poultry and other galliform birds worldwide. However, within the peafowl (Phasianinae) subfamily, there are only rare confirmed reports of MD. Here we report MD in an Indian peafowl (Pavo cristatus), which clinically presented with hindlimb paraparesis and intraocular swelling of the right eye. Soft, off-white to tan masses within the right eye, sciatic nerves and coelomic cavity were identified at post-mortem examination which effaced the cranial pole of the kidneys and diffusely effaced the testes. Lymphoid neoplasia was identified histologically at all of these sites and there was extensive hepatic lymphoid cell infiltration, which had not been grossly evident. The T-cell origin of the lymphoid cells was confirmed by immunohistochemistry for CD3 antigen. A virulent strain of MDV 1 was detected by real-time polymerase chain reaction in DNA samples extracted from the kidney and testes. As MD is rare in peafowl it should be considered as a differential diagnosis for intraocular and coelomic masses with associated clinical signs.

Endoscope and image-guided ventral bulla osteotomy in the dog: A cadaveric and patient study.

BACKGROUND: Surgery of the bulla in the dog can be difficult and associated with suboptimal resolution of disease and risk of complications, particularly in treatment of cholesteatoma. We explored use of image guidance and endoscopic assistance in ventral bulla osteotomy (VBO), initially with cadaveric studies and subsequently on dogs with cholesteatoma. METHODS: For surgical approach we used cone beam CT with an optical image navigation system. For endoscopic surgery we used 4 mm and 2.7 mm diameter endoscopes and a camera viewing system, with micro-instruments for dissection. RESULTS: Image guidance allowed us to accurately identify and approach the bulla in cadavers (n = 2) and patients (n = 2). The endoscope enabled us to define detailed endoscopic anatomy in cadaveric canine heads (n = 15), and in patients (n = 5) it enabled reliable and safe removal of pathological tissue. CONCLUSION: Image and endoscopic assistance could be a significant advance to the reliability and safety of VBO. Our techniques may be applicable to other indications and species.

Cutaneous Vasculopathy and Pulmonary Thromboembolism in an Unstable Diabetic Cat.

A 6-year-old, male-neutered, domestic short-haired cat was referred for further management of a 3-month history of uncontrolled diabetes mellitus. The cat visited the hospital on 3 occasions during a 3-week time period. Hyperglycemia was documented at all visits. The cat initially presented with evidence of hypovolemia, cranial abdominal pain, and dehydration. Moderate hyperglycemia, mild ketonemia, and severe hypokalemia were documented. A 3 × 2 cm skin lesion with associated alopecia and erythema was first noticed at a routine follow-up examination (visit 2) 1 week later. A diagnosis of diabetic ketoacidosis was made 6 days later. The previously identified skin lesion now measured 6 × 2.5 cm. Two episodes of respiratory distress were identified at this visit, with no evidence of cardiac or pulmonary pathology. The cat developed a moderate anemia (packed cell volume 16 %, total solids 7.9 g/dL) on the fifth day of hospitalization. Fluid therapy, electrolyte supplementation, regular insulin, anti-emetic, and analgesia medications were administered during visits 1 and 3. Due to development of anemia, suspected pulmonary thromboembolism events and progression of skin lesions, euthanasia was elected. A diagnosis of cutaneous vasculopathy with secondary ischemic necrosis was made postmortem and pulmonary thromboembolism was confirmed. To the authors' knowledge, this is the first report of cutaneous vasculopathy and pulmonary thromboembolism in a cat with confirmed diabetes mellitus, warranting further research to assess if hypercoagulability is common in this patient population, as routine thromboprophylaxis and anticoagulation may be potentially indicated.

Correlation of minimally invasive imaging techniques to assess intestinal mucosal perfusion with established markers of chronic inflammatory enteropathy in dogs.

BACKGROUND: Minimally invasive diagnostic imaging techniques to detect intestinal inflammation in dogs are lacking. Contrast-enhanced ultrasound (CEUS) and endoscopic narrow band imaging-like endoscopy (Storz Professional Image Enhancement System [SPIES]) might allow quantification of intestinal mucosal perfusion and microvessel density in chronic inflammatory enteropathy (CIE) of dogs. HYPOTHESIS/OBJECTIVES: Markers of mucosal perfusion as determined by CEUS and SPIES endoscopy are potentially useful diagnostic markers to help characterize CIE and correlate with histological inflammation type and severity. ANIMALS: Thirty client-owned dogs diagnosed with CIE at a referral hospital were prospectively enrolled. MATERIALS AND METHODS: Data from CEUS, SPIES, and white light (WL) endoscopy were correlated with World Small Animal Veterinary Association (WSAVA) endoscopy and histology scores and vessel density as determined by immunohistochemistry for von Willebrand factor (vWF). Automated linear modeling was used to determine predictors of endoscopic and histologic severity. RESULTS: Duodenal histology correlated with SPIES data (area percentage value, rho = 0.424, P = .04). White light endoscopy parameters correlated with SPIES parameters in the duodenum. Colonic histology correlated positively with CEUS, whereas colonic CEUS parameters correlated inversely with vWF expression. Several duodenal parameters combined predicted duodenal histology scores to a level of 73.4%. For the colon, 2 parameters contributed more than others to 73.1%. CONCLUSION AND CLINICAL IMPORTANCE: Minimally invasive CEUS and SPIES appear feasible to assess intestinal perfusion in CIE. Use of SPIES endoscopy may be promising for assessing small intestinal inflammation, whereas CEUS could be used to assess colonic perfusion and inflammation. Both techniques need to be investigated further for their clinical utility.

The density of human semen and the validation of weight as an indicator of volume: a multicentre study.

A multi-centre study was undertaken to: a/ determine the density of human semen, and b/ assess the validity of measuring semen volume either volumetrically or gravimetrically. Semen samples from four clinical categories (azoospermia following vasectomy, azoospermia without vasectomy, oligozoospermia (<20x10(6)/ml) and normozoospermia (>/=20x10(6)/ml)) had similar densities (one-way ANOVA: F(3,180)=1.25, not significant), being close to 1.0 g/ml when taken to one decimal place. Measurement of semen volume was then made with either a graduated pipette or by weighing and assuming a density of 1 g/ml. A comparison of the two methods gave an excellent correlation, with a gradient of 1.0571 and a coefficient of determination (R(2)) of 0.98 (p<0.0001). However, it was noted that the aspiration of the ejaculate in to a graduated pipette underestimated the volume by approximately 0.2 ml, but in an inconsistent manner making the use of a set correction factor inappropriate. The estimation of volume to one decimal place by weighing the collection container before and after ejaculation, assuming a density of 1 g/ml, would seem to be a viable alternative although the density of a small number of samples may deviate from this assumption. Whilst the relatively small underestimation of volume with a pipette is unlikely to have clinical significance, the known reporting of inaccurate results by a laboratory is contrary to the philosophy and key principles of quality management.

Effect of Stifle Flexion Angle on the Repeatability of Real-Time Elastosonography of the Patellar Ligament in Medium- to Large-Breed Dogs.

OBJECTIVE: The aims of this study were to describe the elastosonographic findings of the patellar ligament in healthy dogs >15 kg in different positions and determine the most appropriate stifle angle to perform elastosonography of the patellar ligament. STUDY DESIGN: Eighteen clinically healthy dogs, weighing >15 kg, were prospectively recruited. B-mode ultrasound and real-time elastosonography of both patellar ligaments were performed on days 0 and 14. Elastosonography examinations were performed with the stifle in four positions: standing position, lateral recumbency with the stifle positioned at 135 degrees extension and in full passive flexion and extension. RESULTS: The percentage hardness of the patellar ligament was significantly lower when the elastosonographic examination was performed with the dog standing, compared with the other positions (p < 0.005). The variability in the elastosonography readings for each stifle position was lowest when the dog was standing (89.32%). CONCLUSION: Elastosonography is a feasible technique for evaluating the elasticity of the normal canine patellar ligament in dogs >15 kg and would be a useful technique for investigating the mechanical changes within the patellar ligament following stifle surgery. Elastosonography of the patellar ligament should be performed with the dog standing to provide the most accurate elastosonograms with lowest variability between readings.

Naturally-Occurring Canine Mammary Tumors as a Translational Model for Human Breast Cancer.

Despite extensive research over many decades, human breast cancer remains a major worldwide health concern. Advances in pre-clinical and clinical research has led to significant improvements in recent years in how we manage breast cancer patients. Although survival rates of patients suffering from localized disease has improved significantly, the prognosis for patients diagnosed with metastatic disease remains poor with 5-year survival rates at only 25%. In vitro studies using immortalized cell lines and in vivo mouse models, typically using xenografted cell lines or patient derived material, are commonly used to study breast cancer. Although these techniques have undoubtedly increased our molecular understanding of breast cancer, these research models have significant limitations and have contributed to the high attrition rates seen in cancer drug discovery. It is estimated that only 3-6% of drugs that show promise in these pre-clinical models will reach clinical use. Models that can reproduce human breast cancer more accurately are needed if significant advances are to be achieved in improving cancer drug research, treatment outcomes, and prognosis. Canine mammary tumors are a naturally-occurring heterogenous group of cancers that have several features in common with human breast cancer. These similarities include etiology, signaling pathway activation and histological classification. In this review article we discuss the use of naturally-occurring canine mammary tumors as a translational animal model for human breast cancer research.

Neutrophilia is associated with a poorer clinical outcome in dogs with chronic hepatitis.

BACKGROUND: Liver disease is a common cause of morbidity and mortality in dogs. Currently, it is challenging to prognosticate in these cases. The aim of this study was to evaluate the utility of the haematological variables in dogs with chronic hepatitis. METHODS: Dogs with chronic hepatitis confirmed on histopathology had presenting haematological values retrospectively obtained and evaluated against survival time. Eighty-two dogs met the inclusion criteria and their data analysed. RESULTS: Neutrophilic patients, with a count greater than 12×109/l, controlled for sex and age, had a shorter survival time (P≤0.01). In dogs, neutrophilia at presentation predicted a poor outcome, whereas the other haematological parameters were not prognostically informative. When the dogs were split into even quarters on the basis of their neutrophil count, those within the higher quartiles had poorer survival times. Neutrophilia was associated with a poorer survival time in comparison to those patients with a lower count. CONCLUSION: The relationship between neutrophils, inflammation and clinical outcome is deserving of future study in dogs with chronic hepatitis.

Diagnostic features, treatment, and outcome of dogs with inflammatory protein-losing enteropathy.

BACKGROUND: Protein-losing enteropathy (PLE) because of chronic inflammatory enteropathy (CIE) in dogs is often treated with a combination of glucocorticoids and second-line immunosuppressant (SLI). This combined approach might not be necessary in all dogs. HYPOTHESIS/OBJECTIVES: To describe diagnostic features and outcomes of dogs with PLE treated with glucocorticoids alone (group P) or with glucocorticoids and SLI (group S). ANIMALS: Thirty-one dogs with PLE. MATERIAL AND METHODS: Retrospective analysis of signalment data from diagnostic procedures, treatment, and outcome of dogs with CIE/PLE (from 2015 to 2017), using the hospital's digital case database. Dogs with hypoalbuminemia and CIE were included. Because of a stepwise treatment algorithm, dogs were allocated to group P or S. Time to serum albumin concentrations ≥20 g/L and survival data were collected. Dogs were additionally categorized by their albumin and cobalamin serum concentrations. Multivariate and univariate analysis as well as Pearson's correlation and Kaplan-Maier survival analysis were performed. RESULTS: Seventeen dogs were included in group P and 14 in group S. World Small Animal Veterinary Association score of the duodenum was different between groups (P = .05), but none of the other examined data. Median time until serum albumin reached >20 g/L was 13 days. Median survival time after start of treatment was 85 days (range, 13-463 days) in group P and 166 days (range, 8-390 days) in group S. CONCLUSION AND CLINICAL IMPORTANCE: No routine diagnostic test was predictive of clinical response, treatment group, or outcome. Glucocorticoid treatment alone can be appropriate in dogs with PLE.

Biocompatibility of common implantable sensor materials in a tumor xenograft model.

Real-time monitoring of tumor microenvironment parameters using an implanted biosensor could provide valuable information on the dynamic nature of a tumor's biology and its response to treatment. However, following implantation biosensors may lose functionality due to biofouling caused by the foreign body response (FBR). This study developed a novel tumor xenograft model to evaluate the potential of six biomaterials (silicon dioxide, silicon nitride, Parylene-C, Nafion, biocompatible EPOTEK epoxy resin, and platinum) to trigger a FBR when implanted into a solid tumor. Biomaterials were chosen based on their use in the construction of a novel biosensor, designed to measure spatial and temporal changes in intra-tumoral O2 , and pH. None of the biomaterials had any detrimental effect on tumor growth or body weight of the murine host. Immunohistochemistry showed no significant changes in tumor necrosis, hypoxic cell number, proliferation, apoptosis, immune cell infiltration, or collagen deposition. The absence of biofouling supports the use of these materials in biosensors; future investigations in preclinical cancer models are required, with a view to eventual applications in humans. To our knowledge this is the first documented investigation of the effects of modern biomaterials, used in the production of implantable sensors, on tumor tissue after implantation. © 2018 The Authors. Journal of Biomedical Materials Research Part B: Applied Biomaterials published by Wiley Periodicals, Inc. J Biomed Mater Res Part B, 2018. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1620-1633, 2019.

Major histocompatibility complex heterozygosity reduces fitness in experimentally infected mice.

It is often suggested that heterozygosity at major histocompatibility complex (MHC) loci confers enhanced resistance to infectious diseases (heterozygote advantage, HA, hypothesis), and overdominant selection should contribute to the evolution of these highly polymorphic genes. The evidence for the HA hypothesis is mixed and mainly from laboratory studies on inbred congenic mice, leaving the importance of MHC heterozygosity for natural populations unclear. We tested the HA hypothesis by infecting mice, produced by crossbreeding congenic C57BL/10 with wild ones, with different strains of Salmonella, both in laboratory and in large population enclosures. In the laboratory, we found that MHC influenced resistance, despite interacting wild-derived background loci. Surprisingly, resistance was mostly recessive rather than dominant, unlike in most inbred mouse strains, and it was never overdominant. In the enclosures, heterozygotes did not show better resistance, survival, or reproductive success compared to homozygotes. On the contrary, infected heterozygous females produced significantly fewer pups than homozygotes. Our results show that MHC effects are not masked on an outbred genetic background, and that MHC heterozygosity provides no immunological benefits when resistance is recessive, and can actually reduce fitness. These findings challenge the HA hypothesis and emphasize the need for studies on wild, genetically diverse species.

How a Culture of Kindness Can Improve Employee Engagement and Patient Experience - and Five Ways to Get There.

Aware of the evidence demonstrating how important employee engagement is to patient experience, outcomes and cost containment, leadership at Bluewater Health, Sarnia, was looking for strategic solutions to improve engagement. Work with compassion fatigue and resilience specialists suggested focusing on kindness. This article shares the hospital's experience designing and implementing their campaign - from a core committee that empowers and encourages teams to find their own creative ways to promote kindness, through to leadership's commitment to changing organizational culture. There's even a treat cart! Bluewater Health's employee engagement solution has an aspect of fun that is fresh and innovative.

Fanconi Syndrome in Irish Wolfhound Siblings.

Three juvenile male Irish wolfhound littermates presented with marked polyuria and polydipsia. The four female siblings were apparently unaffected. Diagnostic testing revealed glucosuria with normoglycemia, generalized aminoaciduria, hypokalemia and metabolic acidosis consistent with Fanconi syndrome. Renal ultrasonographic and histologic findings are presented. Cases were managed with a supplementation regimen based on a treatment protocol for Fanconi syndrome in basenjis. These dogs did not have angular limb deformities as documented previously in juvenile canine siblings with Fanconi syndrome. Fanconi syndrome has not been previously described in Irish wolfhound siblings.