Anticoagulant rodenticides in urban bobcats: exposure, risk factors and potential effects based on a 16-year study.

Anticoagulant rodenticides (ARs) are increasingly recognized as a threat to nontarget wildlife. High exposure to ARs has been documented globally in nontarget predatory species and linked to the high prevalence of an ectoparasitic disease, notoedric mange. In southern California, mange associated with AR exposure has been the proximate cause of a bobcat (Lynx rufus) population decline. We measured AR exposure in bobcats from two areas in southern California, examining seasonal, demographic and spatial risk factors across landscapes including natural and urbanized areas. The long-term study included bobcats sampled over a 16-year period (1997-2012) and a wide geographic area. We sampled blood (N = 206) and liver (N = 172) to examine exposure ante- and post-mortem. We detected high exposure prevalence (89 %, liver; 39 %, blood) and for individuals with paired liver and blood data (N = 64), 92 % were exposed. Moreover, the animals with the most complete sampling were exposed most frequently to three or more compounds. Toxicant exposure was associated with commercial, residential, and agricultural development. Bobcats of both sexes and age classes were found to be at high risk of exposure, and we documented fetal transfer of multiple ARs. We found a strong association between certain levels of exposure (ppm), and between multiple AR exposure events, and notoedric mange. AR exposure was prevalent throughout both regions sampled and throughout the 16-year time period in the long-term study. ARs pose a substantial threat to bobcats, and likely other mammalian and avian predators, living at the urban-wildland interface.

Development and implementation of a shared governance model in a mainstream health unit: a case study of embedding Aboriginal voices in organisational decision making.

This case study focuses on the development and implementation of a governance structure and processes by a mainstream health unit that valued the principles of Aboriginal self-determination, empowerment and leadership by Aboriginal staff in organisational and service delivery decisions and elevated Aboriginal voices by embedding cultural inclusion in such decision making. Various models of embedding Aboriginal voices in the governance of the unit were developed and implemented over time. Ongoing review and reflection identified limitations and opportunities for improving the embedding of Aboriginal voices in organisational decision making. In 2017, Aboriginal staff and senior management implemented a joint governance model for providing strategic leadership of the unit with the objective of enhancing the delivery of culturally appropriate population health services for the benefit of Aboriginal communities. In its 3 years of operation to date, the model has provided strategic oversight of the organisation, implemented several strategic initiatives, including a cultural assessment process, maintaining and strengthening Aboriginal recruitment, monitoring employment vacancies, establishing a wellbeing leadership group, monitoring budget allocation and developing an Aboriginal data management protocol, and has provided additional professional development opportunities for Aboriginal staff. This case study demonstrates the feasibility, importance and benefits of engaging and embedding Aboriginal voices in the governance of a mainstream health service delivery unit, as well as the need for ongoing reflection and improvement. Further translation of the model to the operational levels of the unit is required. The governance model has the potential to be replicated in a tailored manner in other mainstream health units and organisations delivering services to Aboriginal peoples and communities. What is known about the topic? Aboriginal people continue to experience the poorest health outcomes of any population group in Australia. Closing the gap in Aboriginal health requires Aboriginal people to be active and equal participants in all levels of decision making. Governance of mainstream health organisations is predominantly positioned in the Western medical positivist paradigm, which fails to embed Aboriginal voices in organisational and service delivery decision making. What does this paper add? This case study describes the processes taken and the outcomes achieved thus far by a mainstream health service delivery unit developing and implementing a governance model that embedded Aboriginal perspectives in its decision making. It highlights that through commitment and persistence, as well as acknowledging the challenges of working between two worlds, it is possible to reconstruct existing governance models, allowing respectful and meaningful space for Aboriginal people to co-design and co-share the governance of health service delivery. This case study demonstrates the potential of the cultural governance model to be replicated and applied to other mainstream health service delivery units. What are the implications for practitioners? This case study highlights the need for health services to invest in employing and empowering Aboriginal people to co-develop and co-lead a shared approach to organisational governance through processes that are culturally safe, inclusive and appropriate.

Constructing an ethical framework for priority allocation of pandemic vaccines.

BACKGROUND: Allocation of scarce resources during a pandemic extends to the allocation of vaccines when they eventually become available. We describe a framework for priority vaccine allocation that employed a cross-disciplinary approach, guided by ethical considerations and informed by local risk assessment. METHODS: Published and grey literature was reviewed, and augmented by consultation with key informants, to collate past experience, existing guidelines and emerging strategies for pandemic vaccine deployment. Identified ethical issues and decision-making processes were also included. Concurrently, simulation modelling studies estimated the likely impacts of alternative vaccine allocation approaches. Assembled evidence was presented to a workshop of national experts in pandemic preparedness, vaccine strategy, implementation and ethics. All of this evidence was then used to generate a proposed ethical framework for vaccine priorities best suited to the Australian context. FINDINGS: Published and emerging guidance for priority pandemic vaccine distribution differed widely with respect to strategic objectives, specification of target groups, and explicit discussion of ethical considerations and decision-making processes. Flexibility in response was universally emphasised, informed by real-time assessment of the pandemic impact level, and identification of disproportionately affected groups. Model outputs aided identification of vaccine approaches most likely to achieve overarching goals in pandemics of varying transmissibility and severity. Pandemic response aims deemed most relevant for an Australian framework were: creating and maintaining trust, promoting equity, and reducing harmful outcomes. INTERPRETATION: Defining clear and ethically-defendable objectives for pandemic response in context aids development of flexible and adaptive decision support frameworks and facilitates clear communication and engagement activities.

Priority allocation of pandemic influenza vaccines in Australia - Recommendations of 3 community juries.

BACKGROUND: Pandemic planning has historically been oriented to respond to an influenza virus, with vaccination strategy being a key focus. As the current COVID-19 pandemic plays out, the Australian government is closely monitoring progress towards development of SARS-CoV2 vaccines as a definitive intervention. However, as in any pandemic, initial supply will likely be exceeded by demand due to limited manufacturing output. METHODS: We convened community juries in three Australian locations in 2019 to assess public acceptability and perceived legitimacy of influenza pandemic vaccination distribution strategies. Preparatory work included literature reviews on pandemic vaccine allocation strategies and on vaccine allocation ethics, and simulation modelling studies. We assumed vaccine would be provided to predefined priority groups. Jurors were then asked to recommend one of two strategies for distributing remaining early doses of vaccine: directly vaccinate people at higher risk of adverse outcomes from influenza; or indirectly protect the general population by vaccinating primary school students, who are most likely to spread infection. RESULTS: Thirty-four participants of diverse backgrounds and ages were recruited through random digit dialling and topic-blinded social media advertising. Juries heard evidence and arguments supporting different vaccine distribution strategies, and questioned expert presenters. All three community juries supported prioritising school children for influenza vaccination (aiming for indirect protection), one by 10-2 majority and two by consensus. Justifications included that indirect protection benefits more people and is likely to be more publicly acceptable. CONCLUSIONS: In the context of an influenza pandemic, informed citizens were not opposed to prioritising groups at higher risks of adverse outcomes, but if resources and epidemiological conditions allow, achieving population benefits should be a strategic priority. These insights may inform future SARS-CoV-2 vaccination strategies.

Comparison of the ileal conduit and clean intermittent catheterization for myelomeningocele.

Clean intermittent catheterization has been shown to be a safe and effective means of regular vesical emptying in children with neurogenic bladders secondary to myelomeningocele. The major benefits appear to be the protection of the upper urinary tract, and in many children, improved urinary control. In contrast, the ileal conduit has been shown to produce significant long-term complications; the major one is deterioration of the upper urinary tract. Most children with myelomeningocele begin life with normal kidneys. Our goal of therapy, therefore, is a continent independent child with normal renal function. With proper patient selection, clean intermittent catheterization offers an excellent means of achieving this result in many children; the ileal conduit for permanent urinary diversion in children is outmoded.

Urologic manifestations of Wegener granulomatosis.

Wegener granulomatosis is a disease characterized by necrotizing granulomatous angiitis involving the upper and lower respiratory tracts and the kidneys. The introduction of cyclophosphamide in the treatment of Wegener granulomatosis has dramatically altered the rapidly fatal course of the disease and has altered our thinking regarding its management. Recently we have cared for 3 patients who demonstrated a dramatic spectrum of urinary tract pathology related to Wegener granulomatosis. The cases presented offer three points for consideration by the urologist: (1) the manifestations of the disease in the genitourinary tract can be varied and can present in a dramatic fashion; (2) the rapid progression of renal failure and the nearly uniform mortality associated with the disease have changed largely because of the use of cyclophosphamide; and (3) our approach toward patients with renal failure on the basis of Wegener granulomatosis can be altered, and renal transplantation is certainly feasible with the increased longevity afforded these patients by cyclophosphamide.

Complete ureteral triplication with ectopia.

A case of complete ureteral triplication is reported and a brief review of the literature is presented.

Ileal conduit hemorrhage secondary to portal hypertension.

The clinical features and management of 3 patients who presented with the triad of massive hemorrhage from the ileal conduit, portal hypertension due to liver disease, and portosystemic varices related to the conduits are described. One patient, a class C cirrhotic, was treated conservatively and died of blood loss and hepatic coma. Two patients were managed with splenorenal shunts initially, followed by creation of colon conduits, and are currently doing well. Surgical approximation of areas draining in the portal and systemic circulation with subsequent development or adhesion-related varices probably explains the predilection for involvement of the ileal conduit and may explain the presence of varices in mild to moderate portal hypertension before other signs of hepatic decompensation are evident. Superior mesenteric angiography with special attention directed at the venous phase is necessary to document this entity.

Results in children managed by cutaneous ureterostomy.

A review of 59 children with severe hydronephrosis managed by cutaneous ureterostomy reveals that the procedure is safe, quick, and effective in draining the kidney. Although chronic bacteriuria is common, pyelonephritis is rare. The major drawback of this technique for temporary urinary diversion in children is that the subsequent urinary reconstruction is formidable and more difficult than primary repair. The complications of urinary diversion using this technique are low, however, and it may remain the safest form of diversion available for long-term use in children with dilated ureters.

The use of antirefluxing intestinal segments in pediatric urinary reconstruction.

Because of inadequate ureteral length or disease preventing direct ureterovesical anastomoses, antirefluxing intestinal segments were used in eight children during reconstruction of their urinary tracts. Previous urinary diversions by either ileal conduit or cutaneous ureterostomy had been done in six of the eight. In five of the children, bladder augmentation was also required because of nondistensible fibrotic bladders secondary to disuse or prior obstruction. The intestinal segments used were ileal (4), ileocecal (4), and sigmoid (1). The ileal segments were tapered along the antimesenteric border and reimplanted into the bladder with long submucosal tunnels to prevent reflux. Reflux was prevented in the ileocecal segments by plication of the normal ileocecal valve. Reflux has not developed postoperatively in any of these patients. In one patient in whom an ileal segment was used. In one patient in whom an ileal segment was used, partial obstruction occurred at the new bladder hiatus. The serum creatinine rose from 2.8 mg/dl to 3.5 mg/dl necessitating a secondary repair. Renal function and serum electrolytes have improved or remained stable in all other patients. For children who have undergone multiple previous procedures resulting in inadequate ureteral length and/or abnormal bladders, these techniques offer excellent alternatives to permanent urinary diversion.

Giant hydronephrosis in children.

Twenty pediatric patients with giant hydronephrosis were reviewed. This was defined as a kidney that occupied a hemiabdomen, met or crossed the midline, and was at least 5 vertebrae in length. The majority (16) were cases with ureteropelvic junction obstruction. In 2 cases, the primary pathology was obstructive megaureter. In 2 cases, the infants had severe urethral valves with massive upper tract dilatation. In 6 patients with a normal contralateral kidney, nephrectomy was performed. In one patient with bilateral pathology, one nonfunctioning kidney was removed later. A reconstructive operation was undertaken in 14 of the 20 patients. There was one late death from septicemia in an infant male with urethral valves and bilateral dysplastic kidneys.

Urethral reconstruction in the young female using a perineal pedicle flap.

Five young female patients with a functionally short or absent urethra are described. Two patients had an abnormal urethra related to a congenital malformation (1 female hypospadias, 1 urogenital sinus) and three patients had an absent urethra related to previous surgery. Four of the five patients were totally incontinent of urine. Urethral reconstruction was achieved by tubularizing the mucosa of the vaginal vault and swinging a full thickness pedicle skin flap from the posterior perineum and buttock to cover the urethral repair. In two patients previously diverted, undiversion was made possible. Urinary continence has been achieved in all five patients.

Clean intermittent catheterization for home management in children with myelomeningocele.

Sixty-two children with myelomeningocele and neurogenic bladders have been managed with clean intermittent catheterization (CIC) at home for periods of 6 to 42 months. Abnormal upper urinary tracts improved or stabilized in 83 per cent of the children. There was no renal deterioration in children who began with normal upper tracts while on CIC. Bacteruria was common, but clinically not a problem, unless ureterovesical reflux was present. Urinary control was improved in 66 per cent of the children. CIC is an effective and safe method to regularly empty the urinary bladder and is an alternative to supravesical urinary diversion in many children with neurogenic bladders.

Hematology and serum chemistry of the island fox on Santa Cruz Island.

Serum and hematologic biochemistry values for island foxes (Urocyon littoralis) on Santa Cruz Island (California, USA) in April (wet season) and September (dry season) 1998 were evaluated. Serum chemistry of island foxes generally varied seasonally; 10 (40%) of the 25 serum characteristics were higher in the wet season, and three (12%) of the 25 serum characteristics were higher in the dry season. No hematologic parameters varied between seasons, although some measures varied between sexes. Blood analytes also varied with age; fox pups had higher values than adults for one hematologic and four serum parameters, whereas adult foxes had higher values for five hematologic characteristics. The information on blood chemistry provides baseline data useful in the monitoring of this threatened insular endemic carnivore.

Ectoparasites of the island fox on Santa Cruz Island.

The ectoparasite fauna for island foxes (Urocyon littoralis) on Santa Cruz Island (California, USA) in April (wet season) and September (dry season) 1998 was evaluated. Three taxa of ectoparasites were identified. These were fleas (Pulex irritans), lice (Neotrichodectes mephitidis), and ticks (Ixodes pacificus). Ectoparasite abundances varied seasonally. Typical of insular endemic species, island foxes may be especially vulnerable to the introduction of novel disease organisms and their vectors.

Implementing a rural nursing course.

Southern Alberta is essentially a rural Canadian province and therefore an ideal setting for offering a rural-focused nursing course. Considering the need for professional nurse preparation with a rural focus, three schools of nursing in the Province collaborated to launch their first rural nursing course. The authors elaborate on the process of developing the course, then establishing partnerships with rural communities to provide opportunities for a nursing practicum.