Evidence-based orthopaedic trauma care in the United Kingdom: Guidelines, registries, carrots and sticks.

In the United Kingdom (UK), orthopaedic trauma surgeons utilise evidence-based practice through distillation of high-quality primary research, interrogation of registries and implementation of evidence-based guidelines. Concurrent with this ambition of providing exemplar care based on robust patient centred research, there has evolved a culture of remuneration 'by results'. Therefore, there is a drive for excellence combined with a system of collation and validation of data input as well as remuneration where care excels. There are several organisations involved in each stage of this process, the output of which has much that is pertinent to the globally similar consequences of physical injury. However, their relevance and impact within the UK is magnified as they are written against the backdrop of a unified healthcare system. In this article, we will describe the roles of the different organisations guiding and regulating trauma practice across the UK and discuss how the interplay of these impacts on clinical care.

A quantitative case study assessment of changes to hepatic metabolism from nonlactating grazing dairy cows consuming a large proportion of their diet as fodder beet.

Because of its high yield and the ability of cows to graze it in situ, fodder beet (FB) has become a popular crop in grazing systems, particularly for nonlactating cows. Due to its high sugar content, however, the transition to FB must be managed carefully to avoid rumen acidosis and associated metabolic dysfunction. The initial consumption of FB reduces ruminal pH; however, it is unclear whether this affects liver metabolism and results in systemic inflammation, as has been reported during subacute ruminal acidosis from high-grain diets. We used a quantitative case study approach to undertake additional measurements on a project demonstrating the effects of FB on urinary nitrogen excretion. The objective of our component, therefore, was to determine whether the inclusion of high rates of FB in the diet of nonlactating cows changed indicators of hepatic metabolism relative to a standard diet for nonlactating grazing cows. During the nonlactating period, multiparous, pregnant Holstein-Friesian cows were randomly assigned (n = 15 per treatment) to either pasture (8 kg of DM/cow per day) with corn silage (4 kg of DM/cow per day; PA) or transitioning onto an FB diet (8 kg of DM/cow per day) with pasture silage (4 kg of DM/cow per day; BT) over 14 d. Blood was sampled and the liver was biopsied during the adaptation period and after 7 d of full diet allocation. The hepatic expression of genes involved in peroxisomal oxidation was increased in cows adapting to FB, whereas the expression of genes involved in mitochondrial oxidation was increased when cows were on their full allocation of FB. These results indicate changes to fatty acid metabolism with FB consumption. Expression of 2 genes involved in the unfolded protein response was greater during the adaptation period in cows consuming FB, potentially reflecting negative effects of transitioning onto the FB diet on hepatic metabolism. Interestingly, expression of genes involved in the methionine cycle was increased in the BT cows. We hypothesize that this is a result of FB betaine absorption, although it is unclear to what extent betaine escapes ruminal degradation. While on the full diet allocation, there were lower serum concentrations of markers of hepatic stress in BT cows and no difference in expression of genes involved in oxidative stress compared with pasture-fed cows. However, there was an increase in plasma haptoglobin concentrations, indicative of an acute inflammatory response in BT cows. From this case study, we conclude that the results indicate no negative effects of the FB diet on liver metabolism and, possibly, positive effects on hepatic function. It appears, therefore, that the transition of nonlactating cows onto an FB diet can be managed to minimize the negative effects of the high sugar intake. Further research on the amount of betaine that escapes ruminal degradation in cows consuming FB would be of value to better understand whether betaine reduces liver damage in dairy cows consuming FB.

Once-daily milking during late lactation in pasture-fed dairy cows has minor effects on feed intake, body condition score gain, and hepatic gene expression.

Milking cows once daily (1×) is a management practice occasionally used during mid/late lactation in pasture-based systems. It has been postulated that 1× milking will reduce dry matter intake (DMI) and increase body condition score (BCS) gain; however, this has not been quantified. Lactating, pregnant Holstein-Friesian dairy cows (n=52) were allocated to either 1× or twice-daily (2×) milking in mid-January (summer, 175d in milk). To obtain accurate DMI measurements, cows underwent 4 periods in a Calan gate indoor feeding facility, interspersed with grazing outdoors. Milk production, body weight (BW), and BCS were recorded 2 wk before treatment start (-2 wk) and weekly thereafter. Blood variables were recorded at -2 wk and weekly when indoors. Liver was biopsied at -2, 2, and 10 wk, and hepatic gene expression measured using quantitative PCR. Milking cows 1× tended to lower DMI (17.8 vs. 18.2 kg of dry matter), but increased BCS gain (0.36 vs. 0.13 BCS units) and BW (546 vs. 533 kg) at wk 12 relative to 2×. The greater BCS and BW of cows milked 1× compared with 2× were reflected in lower plasma concentrations of nonesterified fatty acids and lower transcription of genes involved in the oxidation of fatty acids, indicating reduced release and processing of fatty acids. Cows milked 1× produced 20% less milk, and although milk fat and protein concentrations were increased relative to cows milked 2×, yields of fat and protein were 14 and 17% less, respectively. The reduction in milk production with 1× milking (14.1 vs. 16.8 kg/cow per d energy-corrected milk) was accompanied by increases in blood concentrations of glucose and insulin, with a concurrent decrease in the transcription of the insulin receptor and gluconeogenic genes. These results indicate a coordinated response to reduce glucose production due to decreased mammary demand. Expression of 2 genes linked to inflammation and adipokine signaling was reduced in cows milked 1× and may indicate a lower inflammatory state in the liver of cows milked 1× in late lactation. No effect was found of milking frequency during late lactation on milk production in the subsequent lactation. In summary, although 1× milking tended to reduce DMI and increase BCS in late lactation, these effects were lower than what is commonly supposed in pasture-based dairy systems. The modest BCS gains need to be considered with the reduced milk production when adopting 1× milking as a management strategy.

Epigenetic regulation of pyruvate carboxylase gene expression in the postpartum liver.

Hepatic gluconeogenesis is essential for maintenance of whole body glucose homeostasis and glucose supply for mammary lactose synthesis in the dairy cow. Upregulation of the gluconeogenic enzyme pyruvate carboxylase (PC) during the transition period is vital in the adaptation to the greater glucose demands associated with peripartum lactogenesis. The objective of this study was to determine if PC transcription in hepatocytes is regulated by DNA methylation and if treatment with a nonsteroidal anti-inflammatory drug (NSAID) alters methylation of an upstream DNA sequence defined as promoter 1. Dairy cows were left untreated (n=20), or treated with a NSAID during the first 5 d postcalving (n=20). Liver was biopsied at d 7 precalving and d 7, 14, and 28 postcalving. Total PC and transcript specific gene expression was quantified using quantitative PCR and DNA methylation of promoter 1 was quantified using bisulfite Sanger sequencing. Expression of PC changed over the transition period, with increased expression postcalving occurring concurrently with increased circulating concentration of nonesterified fatty acids. The DNA methylation percentage was variable at all sites quantified and ranged from 21 to 54% across the 15 CpG dinucleotides within promoter 1. The DNA methylation at wk 1 postcalving, however, was not correlated with gene expression of promoter 1-regulated transcripts and we did not detect an effect of NSAID treatment on DNA methylation or PC gene expression. Our results do not support a role for DNA methylation in regulating promoter 1-driven gene expression of PC at wk 1 postcalving. Further research is required to determine the mechanisms regulating increased PC expression over the transition period.

Cryptosporidium-associated enteritis in captive koalas (Phascolarctos cinereus).

Cryptosporidium spp. sporadically infect a range of Australian native mammals including koalas, red kangaroos, eastern grey kangaroos, bilbies and brush tailed possums and can range from asymptomatic to fatal infections. Traditionally considered a disease of the young or immuno-compromised, and resulting in profuse diarrhoea in other species, here we report an atypical clinical syndrome associated with Cryptosporidium in a captive population of koalas. All affected animals were in-contact adults, and demonstrated anorexia, dehydration and abdominal pain in the absence of diarrhoea. Following euthanasia on welfare grounds, Cryptosporidium infection was confirmed postmortem in three of four symptomatic animals via faecal floatation and/or intestinal histopathology, with enteritis also diagnosed in the fourth koala. Further screening of the captive colony found the outbreak had been contained. Based on sequencing the cause of the infection was C. fayeri, but the source was undetermined. In conclusion, Cryptosporidium should be considered as a possible cause of generalised illness in koalas.

Ehrlichia canis rapid spread and possible enzooty in northern South Australia and distribution of its vector Rhipicephalus linnaei.

Recent concerns have arisen in Australia regarding detections of the exotic bacterium Ehrlichia canis which has resulted in ehrlichiosis outbreaks. In Australia, it is spread by the tropical brown dog tick Rhipicephalus linnaei, formerly Rhipicephalus sanguineus sensu lato tropical lineage. Previously, the tick has been recorded in South Australia in the Coober Pedy and the Oodnadatta areas. This study, which includes historical specimens data held in historical Australian arthropod collections, along with 10 sampled remote communities, confirms the wide distribution range of this species within the State. E. canis was detected by PCR in the ticks. The percentage of dogs hosting PCR-positive ticks increased from 2.8% (95% confidence interval [CI]: 0.3 to 9.7) in November-December 2020 to 62.9% (95% CI: 44.9 to 78.5) end of February 2021, initially in two then in seven Anangu Pitjantjatjara Yankunytjatjara lands communities in the far northern regions of South Australia. Our results suggest a rapid spread of the pathogen. No evidence of E. canis was found in nine regional communities. The extended tropical brown dog tick distribution indicates a greater area where E. canis may occur and may require management to minimise the impacts of ehrlichiosis outbreaks. Without the implementation of effective detection and control programs, this extended distribution of R. linnaei is likely to result in the spread of the bacterium to other regions.

Seropositivity to Campylobacter and association with abortion and lamb mortality in maiden ewes from Western Australia, South Australia and Victoria.

This case-control study investigated associations between Campylobacter fetus or Campylobacter jejuni titre and reproductive outcomes in 22 flocks of Merino and non-Merino maiden ewes aged 1-2 years old. Campylobacter titres were also determined for multiparous ewes aged 3 years or older on the same farms. C. fetus 'positivity' (titre ≥1:80) was detected for 12% (57/462; 95% confidence interval [95% CI] 9.6 to 15.6) of maiden ewes and 31% (65/210; 95% CI 25.0 to 37.4) of mature ewes. The odds for failing to rear a lamb in C. fetus-'exposed' maiden ewes (titre ≥1:10) was 2.01 times that of seronegative ewes (95% CI 1.09 to 3.77; P = 0.027), but there was no association between C. fetus-'positivity' (titre ≥1:80) and failure to rise (OR 1.69; 95% CI 0.77 to 3.76; P = 0.191). C. fetus abortions were confirmed with microbial culture in one maiden ewe flock. In this flock, C. fetus titres fluctuated and often waned by lamb marking, highlighting the value of necropsies during abortion investigations. C. jejuni-'positivity' (titre ≥1:80) was detected for 44% (204/462; 95% CI 39.7 to 48.7) maiden ewes, but odds of failing to rear were decreased for C. jejuni-'positive' ewes (OR 0.52; 95% CI 0.32 to 0.83; P = 0.007). The association between Campylobacter serology and the reproductive outcome was inconsistent in these flocks. Serology should be considered in the context of other risk factors and used in conjunction with other strategies to investigate the impact of Campylobacter exposure on ewe reproductive performance such as monitoring for abortions and lamb necropsies to determine aetiological diagnosis, and vaccination trials.

Abnormal cortisol awakening response predicts worse cognitive function in patients with first-episode psychosis.

BACKGROUND: Cognitive impairment, particularly in memory and executive function, is a core feature of psychosis. Moreover, psychosis is characterized by a more prominent history of stress exposure, and by dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. In turn, stress exposure and abnormal levels of the main HPA axis hormone cortisol are associated with cognitive impairments in a variety of clinical and experimental samples; however, this association has never been examined in first-episode psychosis (FEP). METHOD: In this study, 30 FEP patients and 26 controls completed assessment of the HPA axis (cortisol awakening response and cortisol levels during the day), perceived stress, recent life events, history of childhood trauma, and cognitive function. The neuropsychological battery comprised general cognitive function, verbal and non-verbal memory, executive function, perception, visuospatial abilities, processing speed, and general knowledge. RESULTS: Patients performed significantly worse on all cognitive domains compared to controls. In patients only, a more blunted cortisol awakening response (that is, more abnormal) was associated with a more severe deficit in verbal memory and processing speed. In controls only, higher levels of perceived stress and more recent life events were associated with a worse performance in executive function and perception and visuospatial abilities. CONCLUSIONS: These data support a role for the HPA axis, as measured by cortisol awakening response, in modulating cognitive function in patients with psychosis; however, this association does not seem to be related to the increased exposure to psychosocial stressors described in these patients.

Comparative susceptibility of planktonic and 3-day-old Salmonella Typhimurium biofilms to disinfectants.

AIMS: To compare the susceptibility of a 3-day-old biofilm and planktonic Salmonella to disinfectants at different exposure times. We hypothesize that Salmonella biofilms are more resilient to disinfectants compared to planktonic Salmonella. METHODS AND RESULTS: The susceptibility of planktonic cells to disinfectants was tested by a modified version of the Council of Europe suspension test EN 1276. Salmonella biofilms were formed using the Calgary Biofilm Device. Results show that 3-day-old Salmonella biofilms are less susceptible to the disinfectants benzalkonium chloride, chlorhexidine gluconate, citric acid, quaternary ammonium compounds, sodium hypochlorite (SH) and ethanol, compared to planktonic Salmonella. Surprisingly, the results also demonstrate that low concentrations of SH were more effective against a 3-day-old biofilm compared to high concentrations of SH. CONCLUSIONS: While all the disinfectants evaluated were able to reduce biofilm-associated cells at concentrations and contact times sufficient to eliminate planktonic cells, there were still sufficient viable cells remaining in the biofilm to cause further contamination and potential infection. SIGNIFICANCE AND IMPACT OF THE STUDY: Protocols for the use of chemical disinfectants need to include biofilm susceptibility testing. There is a requirement for an effective and standardized tool for determining the susceptibility of biofilms to disinfectants.

Relationship between Toxoplasma gondii seroprevalence and lamb marking in South Australian sheep flocks.

OBJECTIVE: Toxoplasmosis in sheep has negative impacts on reproductive performance. This study aimed to estimate the prevalence in Toxoplasma gondii infection in the South Australian sheep population, and assess any association between within-flock prevalence and reproductive efficiency (measured by lamb marking percentage), climatic region and rainfall. METHODS: A total of 875 individual mixed-age breeding ewes from 29 South Australian properties were blood sampled with an average of 30.2 ewes per property (min 28, max 32). Sera were tested for T. gondii-specific IgG antibody using a commercial Modified Agglutination Test kit. RESULTS: Overall, 209 of 875 (23.9%; 95% confidence interval [CI] 16.3% to 31.4%) of individual ewes tested seropositive for T. gondii-specific IgG antibodies, with a flock level seroprevalence of 28/29 (96.6%, 95% CI 96.6% to 100%). On individual farms, the seroprevalence ranged from 0% to 93.3%. Analysis showed that Kangaroo Island properties had significantly higher mean seroprevalence than any mainland climatic regions, and that the mainland regions did not significantly differ from each other. Linear regression revealed a significant association between seroprevalence and lamb marking percentage, with a slope of -5.4% lamb marking per +10% seroprevalence.

Evidence of infection with Toxoplasma gondii and Neospora caninum in South Australia: using wild rabbits as a sentinel species.

OBJECTIVE: The aim of this study was to utilise wild rabbits (Oryctolagus cuniculus) as a sentinel species to study levels of environmental contamination with N. caninum and T. gondii in South Australia, and to examine associations with rainfall, climate and land use. DESIGN: Toxoplasma gondii (T. gondii), an apicomplexan parasite, causes the clinical disease toxoplasmosis, which can affect sheep as well as humans and many other animals. Neosporosis, the clinical disease caused by closely related Neospora caninum (N. caninum), causes abortions in cattle, with large economic impacts to cattle industries. METHODS: Aliquots of wild rabbit (Oryctolagus cuniculus) serum were obtained from twelve sites across South Australia over a period of eighteen years, with a total of 2114 samples. An in-house Modified Agglutination Test (MAT) was developed, and samples were screened for the specific antibodies against both T.gondii and N. caninum. RESULTS: Overall, 9.9% of samples screened for T. gondii tested positive and 6.1% of samples screened for N. caninum tested positive. There was no difference observed in seroprevalence of T.gondii specific antibodies between samples collected throughout summer, autumn, winter or spring. By contrast, a significantly higher (p=0.030) seroprevalence of N. caninum specific antibodies was observed in spring than any other season. T. gondii and N. caninum antibodies were discovered at sites across a broad area of South Australia, indicating these environments maybe infected with both parasites. CONCLUSION: Results provide evidence that suggests N. caninum oocysts may have different survival characteristics, such as varying tolerances to low relative humidity, than T. gondii oocysts.

Vertical transmission of Toxoplasma gondii in Australian marsupials.

To date, little is known about the dynamics of vertical transmission of Toxoplasma gondii in Australian marsupials. Studies in mice demonstrate that vertical transmission of T. gondii is common and that chronically infected mice can transmit T. gondii to successive generations. In this study, PCR and immunohistochemistry were used to detect T. gondii in chronically infected marsupial dams and their offspring. T. gondii was detected in the unfurred pouch young of 2 out of 10 chronically infected western grey kangaroos (Macropus fuliginosus) and in the unfurred pouch young of a brush-tailed bettong (Bettongia penicillata). Results of the study suggest that vertical transmission of T. gondii can occur in chronically infected Australian marsupials.

Is canine heartworm (Dirofilaria immitis) endemic to South Australia?

BACKGROUND: Canine heartworm (Dirofilaria immitis) was reported as endemic to South Australia over 25 years ago, but the current status of canine heartworm infection in South Australia is unknown. METHODS: We surveyed South Australian veterinary practices to collect evidence about canine heartworm cases, prevention, screening and treatment practices. RESULTS: In total, 141 veterinary practices operating in South Australia (92.3% response rate) completed a 12-question telephone survey. Five confirmed cases of heartworm and one suspected false-positive case were reported from separate practices over the 2016-17 financial year. All confirmed cases had recently relocated to South Australia from interstate. Incidence of canine heartworm was estimated at 0.00% (95% confidence interval (CI): 0.00-0.0006) and prevalence at 0.002% (95%CI: 0.00-0.004) using conservative estimates of the South Australian dog population. Attitudes and protocols regarding heartworm differed significantly between metropolitan and rural veterinary practices. All metropolitan practices recommend systematic medicated prevention against heartworm, while some rural practices (20.7%) recommend prevention only when travelling interstate (P < 0.001). CONCLUSION: Although there is a minor source of heartworm from introduction of infected dogs into South Australia, there is no evidence that the infection is transmitted to other dogs within the state. Therefore, it is unlikely that heartworm is currently endemic to South Australia as reported in the past. This new evidence provides a strong case to refine current prevention practices to reflect the current negligible risk of heartworm infection within South Australia.

Alpha 2 giardin is an assemblage A-specific protein of human infective Giardia duodenalis.

Of the 7 genetic assemblages of the parasite Giardia duodenalis only 2 (A and B) are known to cause infections in humans. These assemblages have been characterized in detail at the genomic level but few studies have examined differences in the proteins expressed. Employing one and two-dimensional PAGE we have identified an assemblage A-specific protein of human infective G. duodenalis; alpha 2 giardin. The protein difference was evident using both electrophoretic techniques. Alpha 2 giardin is known to be a structural protein and associates with the caudal flagella and the plasma membrane; however, its exact function is unknown. Although several proteins unique to assemblage B were also observed, we were unable to identify these proteins due to a lack of genomic data available for assemblage B isolates. Together, these proteins represent distinct phenotypic differences between the human infective assemblages of G. duodenalis and support the need to revise the taxonomy of this parasite.

Seroprevalence of antibodies to Pestivirus infections in South Australian sheep flocks.

OBJECTIVE: Bovine viral diarrhoea virus (BVDV) and border disease virus (BDV) are of the genus Pestivirus. They are known to cause significant reproductive and production losses, with BVDV acknowledged as a major source of economic loss to the Australian cattle industry. Very little is currently known about the prevalence and effect of pestiviruses in the Australian sheep industry. The present study aimed to examine the seroprevalence and effect of both BVDV and BDV in South Australian sheep flocks. METHODS: In total, 875 breeding ewes on 29 properties were serologically tested by ELISA, AGID and VNT assays for the presence of Pestivirus-specific antibodies. RESULTS: Three (0.34%) individual animals returned serological results suggestive of previous BDV infection. All three positive animals were collected from one property, giving a property level seroprevalence of 3.45% and a within-flock seroprevalence of 10%. CONCLUSION: The results suggested that BDV infection is present, albeit at a very low incidence, in the South Australian sheep flock and BVDV infection appears to be absent. Consequently, pestiviruses are unlikely to impair production in South Australian sheep populations.

Comparison of serological methods for the diagnosis of Neospora caninum infection in cattle.

The aims of this study were to evaluate the performance and agreement of various commercial and in-house Neospora caninum antibody assays used in dairy cattle in North America, and to investigate reproducibility of two assays performed in different laboratories. From 1998 to 2005, three enzyme linked immunosorbent assays (ELISAs, a competitive ELISA-VMRD Inc., an indirect ELISA-Biovet Inc., and another indirect ELISA-Herdchek IDEXX Corp.), two indirect fluorescent antibody tests (IFATs, VMRD Inc., and in-house USDA) and one N. caninum agglutination test (NAT, in-house USDA) were utilized to test 397 randomly selected dairy cattle serum samples from 34 herds in eastern Canada for antibodies to N. caninum. The manufacturers' recommended cut-off values were used to evaluate test performance and agreement between tests. One IFAT (VMRD Inc.) performed well (sensitivity and specificity: 0.97 and 0.97, respectively) using reference sera (n = 452), therefore, results from this IFAT on the 397 samples could subsequently be used as the reference standard to calculate test characteristics for the other assays. Only 11% of the 397 sera were found to be N. caninum-positive with the IFAT. Prevalence-adjusted bias-adjusted kappa (PABAK) ranged from 0.06 to 0.99. Positive agreement was moderate to very good (P(pos) = 0.25-0.96). Negative agreement was very good for all assays (P(neg) > 0.94) except NAT (P(neg) = 0.66). Sensitivity was > or =0.89 for all assays except the NAT, which had a significantly lower sensitivity (0.66). Specificity was high (>0.94) for all assays except for one indirect ELISA (specificity = 0.52). This indirect ELISA did not perform satisfactorily when used in 1998, but an improved version of the ELISA performed as one of the best assays in 2004. Reproducibility of the competitive ELISA was excellent, but the reproducibility of the indirect ELISA that was improved was low (concordance correlation coefficient = 0.90 and 0.36, respectively). The performance characteristics observed for most assays in this study make them useful for screening antibodies to N. caninum in cattle.

Evaluation of four serological techniques to determine the seroprevalence of Neospora caninum in foxes (Vulpes vulpes) and coyotes (Canis latrans) on Prince Edward Island, Canada.

The objectives of this study were (1) to evaluate the performance and agreement of serological assays (ELISA, IFAT, Neospora caninum agglutination test and immunoblot) using reference sera and field sera from foxes and coyotes and (2) to estimate the N. caninum seroprevalence in foxes and coyotes on Prince Edward Island, Canada. With fox and coyote reference sera the test performance of the ELISA, IFAT and IB was excellent (100% sensitivity and specificity). NAT showed a low sensitivity (50%). Serum was collected from 201 coyotes and 271 foxes. The seroprevalence observed in the different assays ranged from 0.5 to 14.0% in coyotes and 1.1 to 34.8% in foxes. The seroprevalence, when taking more than one test positive as cut-off value was 3.3 and 1.1% for coyotes and foxes, respectively. From the N. caninum-positive group, all coyotes were older than 3 years. Agreement among assays (measured as prevalence-adjusted bias-adjusted kappa) using the field sera ranged from 0.17 to 0.97. Best agreement was observed between ELISA and IFAT, poor agreement was observed between NAT and the other assays. Positive agreement was moderate to poor among all assays utilized in this study. Although the seroprevalence observed was low, N. caninum antibodies are present in foxes and coyotes on Prince Edward Island (PEI) and their role in the N. caninum epidemiology needs further study.

Ixodes scapularis ticks collected by passive surveillance in Canada: analysis of geographic distribution and infection with Lyme borreliosis agent Borrelia burgdorferi.

Passive surveillance for the occurrence of the tick Ixodes scapularis Say (1821) and their infection with the Lyme borreliosis spirochaetes Borrelia burgdorferi s.l. has taken place in Canada since early 1990. Ticks have been submitted from members of the public, veterinarians, and medical practitioners to provincial, federal, and university laboratories for identification, and the data have been collated and B. burgdorferi detected at the National Microbiology Laboratory. The locations of collection of 2,319 submitted I. scapularis were mapped, and we investigated potential risk factors for I. scapularis occurrence (in Quebec as a case study) by using regression analysis and spatial statistics. Ticks were submitted from all provinces east of Alberta, most from areas where resident I. scapularis populations are unknown. Most were adult ticks and were collected in spring and autumn. In southern Québec, risk factors for tick occurrence were lower latitude and remote-sensed indices for land cover with woodland. B. burgdorferi infection, identified by conventional and molecular methods, was detected in 12.5% of 1,816 ticks, including 10.1% of the 256 ticks that were collected from humans and tested. Our study suggests that B. burgdorferi-infected I. scapularis can be found over a wide geographic range in Canada, although most may be adventitious ticks carried from endemic areas in the United States and Canada by migrating birds. The risk of Lyme borreliosis in Canada may therefore be mostly low but more geographically widespread than previously suspected.

A unified theory of bone healing and nonunion: BHN theory.

This article presents a unified clinical theory that links established facts about the physiology of bone and homeostasis, with those involved in the healing of fractures and the development of nonunion. The key to this theory is the concept that the tissue that forms in and around a fracture should be considered a specific functional entity. This 'bone-healing unit' produces a physiological response to its biological and mechanical environment, which leads to the normal healing of bone. This tissue responds to mechanical forces and functions according to Wolff's law, Perren's strain theory and Frost's concept of the "mechanostat". In response to the local mechanical environment, the bone-healing unit normally changes with time, producing different tissues that can tolerate various levels of strain. The normal result is the formation of bone that bridges the fracture - healing by callus. Nonunion occurs when the bone-healing unit fails either due to mechanical or biological problems or a combination of both. In clinical practice, the majority of nonunions are due to mechanical problems with instability, resulting in too much strain at the fracture site. In most nonunions, there is an intact bone-healing unit. We suggest that this maintains its biological potential to heal, but fails to function due to the mechanical conditions. The theory predicts the healing pattern of multifragmentary fractures and the observed morphological characteristics of different nonunions. It suggests that the majority of nonunions will heal if the correct mechanical environment is produced by surgery, without the need for biological adjuncts such as autologous bone graft. Cite this article: Bone Joint J 2016;98-B:884-91.

Expressed emotion: from predictive index to clinical construct.

Expressed emotion, a measure of family attitudes toward psychiatric patients that is predictive of relapse, has attracted renewed attention recently as interest in the chronic psychiatric patient has widened. The authors review the development of the concept and the limits of its meaning. In seeking the core clinical construct underlying the expressed emotion variable, the authors also review recent studies of the relationship of expressed emotion to family interaction patterns, physiological arousal states, precipitants of relapse, and parental personality style. While family intervention studies are necessary to demonstrate that expressed emotion influences outcome in psychiatric patients, methodological limitations in currently available studies leave this issue unresolved.