Fatal Rodentborne Leptospirosis in Prison Inmates, South Africa, 2015.

Leptospirosis is a neglected zoonotic disease. In 2015, leptospirosis was diagnosed in 2 prison inmates in South Africa. Using real-time PCR and DNA sequencing, we identified Leptospira interrogans serogroup Icterohaemorrhagiae in rodents and water samples within the prison. Leptospirosis might be frequently underdiagnosed in South Africa.

Leptospira in livestock in Madagascar: uncultured strains, mixed infections and small mammal-livestock transmission highlight challenges in controlling and diagnosing leptospirosis in the developing world.

In developing countries, estimates of the prevalence and diversity of Leptospira infections in livestock, an important but neglected zoonotic pathogen and cause of livestock productivity loss, are lacking. In Madagascar, abattoir sampling of cattle and pigs demonstrated a prevalence of infection of 20% in cattle and 5% in pigs by real-time PCR. In cattle, amplification and sequencing of the Leptospira-specific lfb1 gene revealed novel genotypes, mixed infections of two or more Leptospira species and evidence for potential transmission between small mammals and cattle. Sequencing of the secY gene demonstrated genetic similarities between Leptospira detected in Madagascar and, as yet, uncultured Leptospira strains identified in Tanzania, Reunion and Brazil. Detection of Leptospira DNA in the same animal was more likely in urine samples or pooled samples from four kidney lobes relative to samples collected from a single kidney lobe, suggesting an effect of sampling method on detection. In pigs, no molecular typing of positive samples was possible. Further research into the epidemiology of livestock leptospirosis in developing countries is needed to inform efforts to reduce human infections and to improve livestock productivity.

Mixed Leptospira Infections in a Diverse Reservoir Host Community, Madagascar, 2013-2015.

We identified mixed infections of pathogenic Leptospira in small mammals across a landscape-scale study area in Madagascar by using primers targeting different Leptospira spp. Using targeted primers increased prevalence estimates and evidence for transmission between endemic and invasive hosts. Future studies should assess rodentborne transmission of Leptospira to humans.

The retrieval of fingerprint friction ridge detail from elephant ivory using reduced-scale magnetic and non-magnetic powdering materials.

An evaluation of reduced-size particle powdering methods for the recovery of usable fingermark ridge detail from elephant ivory is presented herein for the first time as a practical and cost-effective tool in forensic analysis. Of two reduced-size powder material types tested, powders with particle sizes ≤ 40 µm offered better chances of recovering ridge detail from unpolished ivory in comparison to a conventional powder material. The quality of developed ridge detail of these powders was also assessed for comparison and automated search suitability. Powder materials and the enhanced ridge detail on ivory were analysed by scanning electron microscopy and energy dispersive X-ray spectroscopy and interactions between their constituents and the ivory discussed. The effect of ageing on the quality of ridge detail recovered showed that the best quality was obtained within 1 week. However, some ridge detail could still be developed up to 28 days after deposition. Cyanoacrylate and fluorescently-labelled cyanoacrylate fuming of ridge detail on ivory was explored and was less effective than reduced-scale powdering in general. This research contributes to the understanding and potential application of smaller scale powdering materials for the development of ridge detail on hard, semi-porous biological material typically seized in wildlife-related crimes.

Clinical evaluation of suspected deep vein thrombosis guides the decision to anticoagulate prophylactically but does not impact the decision to perform after hours duplex venous scanning or increase its yield.

OBJECTIVE: The utility of after-hours duplex venous scanning (DVS) for suspected deep vein thrombosis (DVT) in emergency department (ED) patients has been debated. Availability of safe prophylactic low molecular weight heparin, cost containment efforts, and retention of scarce sonographers have to be balanced against 24/7 demand for services. We determined the incidence of DVT in DVS ordered after-hours, correlation between Wells' score and prophylactic anticoagulation as well as urgently performed DVS, and complications of delaying DVS until regular hours. METHODS: Records of all ED encounters between July 1, 2009 and June 30, 2010 associated with a DVS ordered after-hours were reviewed. The decisions to prophylactically anticoagulate and whether to perform DVS urgently or delayed until regular hours were at the discretion of the ED physician and a vascular surgeon. DVS findings, number of urgent and delayed studies, Wells' scores, D-dimers, and outcomes were recorded. RESULTS: DVT was found in 12% (22) of 181 DVS ordered after-hours. DVT was found in 19% of 42 DVS done urgently and in 10% of 139 DVS delayed an average 10 hours 17 minutes (P = NS). All patients had Wells' scores and 43 had D-dimers. Furthermore, 76% of patients with a Wells' score ≥3 had prophylactic anticoagulation whereas only 39% of patients with a Wells' score <3 had prophylactic anticoagulation (P = .0001). In contrast, 36% of patients with a Wells' score ≥3 had urgent DVS and 20% of patients with a Wells' score <3 had urgent DVS (P = NS). Prophylactic anticoagulation was given to 86% of patients eventually found to have DVT vs 40% of patients eventually found to have no DVT (P < .0001). There were no pulmonary emboli or bleeding complications. CONCLUSIONS: The incidence of DVT in ED patients who had urgent after-hours DVS was no different than in those whose DVS was delayed until regular hours. High pretest probability can be achieved with clinical evaluation prior to DVS, and this guided the decision to prophylactically anticoagulate but did not impact the decision to perform urgent DVS. Most patients eventually found to have DVT did receive prophylactic anticoagulation, and delay of DVS did not result in complications. We believe that most patients in whom there is high clinical suspicion for DVT can safely get prophylactic anticoagulation and delayed DVS. Patients in whom there is low clinical suspicion should not get urgent DVS.

Effect of advanced age and vital signs on admission from an ED observation unit.

OBJECTIVES: The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission. METHODS: We conducted a prospective, observational cohort study of ED patients placed in an ED-based observation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at a cutoff of 65 years or more. Vital signs were examined continuously and at commonly accepted cutoffs.We additionally controlled for demographics, comorbid conditions, laboratory values, and observation protocol. RESULTS: Three hundred patients were enrolled, 12% (n = 35) were 65 years or older, and 11% (n = 33) required admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07%-14.9%) in older adults and 12.1% (95% CI, 8.4%-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR], 0.30; 95% CI, 0.05-1.67). Predictors of admission included systolic pressure 180 mm Hg or greater (OR, 4.19; 95% CI, 1.08-16.30), log Charlson comorbidity score (OR, 2.93; 95% CI, 1.57-5.46), and white blood cell count 14,000/mm(3) or greater (OR, 11.35; 95% CI, 3.42-37.72). CONCLUSIONS: Among patients placed in an ED observation unit, age 65 years or more is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure 180 mm Hg or greater was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion.

Advancing animal tuberculosis surveillance using culture-independent long-read whole-genome sequencing.

Animal tuberculosis is a significant infectious disease affecting both livestock and wildlife populations worldwide. Effective disease surveillance and characterization of Mycobacterium bovis (M. bovis) strains are essential for understanding transmission dynamics and implementing control measures. Currently, sequencing of genomic information has relied on culture-based methods, which are time-consuming, resource-demanding, and concerning in terms of biosafety. This study explores the use of culture-independent long-read whole-genome sequencing (WGS) for a better understanding of M. bovis epidemiology in African buffaloes (Syncerus caffer). By comparing two sequencing approaches, we evaluated the efficacy of Illumina WGS performed on culture extracts and culture-independent Oxford Nanopore adaptive sampling (NAS). Our objective was to assess the potential of NAS to detect genomic variants without sample culture. In addition, culture-independent amplicon sequencing, targeting mycobacterial-specific housekeeping and full-length 16S rRNA genes, was applied to investigate the presence of microorganisms, including nontuberculous mycobacteria. The sequencing quality obtained from DNA extracted directly from tissues using NAS is comparable to the sequencing quality of reads generated from culture-derived DNA using both NAS and Illumina technologies. We present a new approach that provides complete and accurate genome sequence reconstruction, culture independently, and using an economically affordable technique.

Accessible digital assessments of temporal, spatial, or movement concepts for profoundly motor impaired and non-verbal individuals: a pilot study.

PURPOSE: Here we present a study of two new Assistive Technology (AT) accessible digital assessments which were developed to address the current paucity of (English) spoken language comprehension assessments accessible to individuals who are both non-verbal and have profound motor impairments. Such individuals may rely heavily upon AT for communication and control. However, many assessments require that responses are given either verbally, by physical pointing or manipulating physical objects. A further problem with many assessments is their reliance upon static images to represent language components involving temporal, spatial or movement concepts. These new assessments aim to address some of these issues. MATERIALS AND METHODS: The assessments were used with 2 young people who are non-verbal and have profound motor impairments (GMFCS level IV/V) and who use eye gaze as their primary method of communication and access. One assessment uses static images and the other short video clips to represent concepts containing temporal, spatial or movement elements. The assessments were carried out with each participant, both before and after an intervention, as part of a larger study. RESULTS: The assessments were accessible using AT (eye gaze) for both participants, although assessment scores varied. The design of the assessments particularly suited one participant who scored near maximum, but they appeared less suitable for the other participant. CONCLUSIONS: Making assessments AT accessible removes a barrier to assessing aspects of the spoken language comprehension abilities of some. Video may be a better medium for representing certain concepts within assessments compared with static images.IMPLICATIONS FOR REHABILITATIONThe new assessments provided a deeper understanding of two members of a group who are traditionally difficult to assess, using two alternative physically accessible methods of assessing the spoken language comprehension of the target group;Accessible assessments are important for assessing complex individuals in order to identify knowledge limitations and set therapy (and education) goals;The alternative access features of communication software can provide a "wrapper" for providing accessibility features to assessments;Video clips may be a better means of representing certain concepts in assessments compared to their static equivalents;Ensuring that assessments are physically accessible is sufficient for the assessment of some individuals, but for some "cognitive" accessibility also needs to be considered.

The Seroepidemiology of a Neglected Zoonotic and Livestock Pathogen in Free-Ranging Bovids: Leptospirosis in African Buffaloes (Syncerus caffer).

Multi-host pathogens are challenging to control and are responsible for some of the most important diseases of humans, livestock, and wildlife. Leptospira spp. are some of the most common multi-host pathogens and represent an important cause of zoonotic infections and livestock productivity loss in the developing world, where contact with wildlife species is common. Although there is increasing evidence that cattle in Africa harbour a broad diversity of Leptospira genotypes and serovars, little is known about the epidemiology of these pathogens in wild bovids, such as African buffaloes (Syncerus caffer). Using microscopic agglutination testing (MAT) on serum samples collected from free-ranging buffaloes (n = 98) captured in the Hluhluwe-iMfolozi Park (HiP), South Africa, we demonstrated an overall seroprevalence of 21% with seropositivity almost exclusively limited to serovar Tarassovi (serogroup Tarassovi). Moreover, we found no evidence of seropositivity in unweaned calves and showed temporal- or herd-specific variation in exposure risk, and increased probability of seropositivity (OR = 5.44, 95% CI = 1.4-27) in female buffaloes. Together, these findings demonstrate that free-ranging African buffaloes are exposed to Leptospira spp. infections, providing insights into the epidemiology of an emerging Leptospira serovar in herds with an absence of any disease control and minimal management.

Multi-locus sequence analyses reveal a clonal L. borgpetersenii genotype in a heterogeneous invasive Rattus spp. community across the City of Johannesburg, South Africa.

BACKGROUND: Rattus spp. are frequently implicated as key reservoir hosts for leptospirosis, one of the most common, but neglected, bacterial zoonoses in the world. Although leptospirosis is predicted to be a significant public health threat in Africa, studies from the continent are limited. METHODS: Rattus spp. (n = 171) were sampled (January-May 2016) across the City of Johannesburg, South Africa's largest inland metropole. Rattus spp. genetic diversity was evaluated by full length (1140 bp) cyt b sequencing of 42 samples. For comparison, a further 12 Rattus norvegicus samples collected in Cape Town, South Africa's largest coastal metropole, were also genotyped. Leptospira infections were identified and genotyped using real-time PCR and multi-locus (lfb1, secY and lipL41) DNA sequencing. RESULTS: Five R. norvegicus haplotypes were identified across Johannesburg, four of which have not previously been detected in South Africa, and one in Cape Town. Across Johannesburg we identified a Leptospira spp. infection prevalence of 44% (75/171) and noted significant differences in the prevalence between administrative regions within the metropole. Multi-locus sequence analyses identified a clonal genotype consistent with L. borgpetersenii serogroup Javanica (serovar Ceylonica). DISCUSSION: The prevalence of infection identified in this study is amongst the highest detected in Rattus spp. in similar contexts across Africa. Despite the complex invasion history suggested by the heterogeneity in R. norvegicus haplotypes identified in Johannesburg, a single L. borgpetersenii genotype was identified in all infected rodents. The lack of L. interrogans in a rodent community dominated by R. norvegicus is notable, given the widely recognised host-pathogen association between these species and evidence for L. interrogans infection in R. norvegicus in Cape Town. It is likely that environmental conditions (cold, dry winters) in Johannesburg may limit the transmission of L. interrogans. Spatial heterogeneity in prevalence suggest that local factors, such as land use, influence disease risk in the metropole. CONCLUSIONS: In South Africa, as in other African countries, leptospirosis is likely underdiagnosed. The high prevalence of infection in urban rodents in Johannesburg suggest that further work is urgently needed to understand the potential public health risk posed by this neglected zoonotic pathogen.

Observation unit economics.

With an aging population, the United States health care delivery system is struggling to handle an onslaught of chronic disease burden. The current process of regulatory oversight and pay-for-performance reimbursement is a reality in today's health care delivery system. To maintain profitability, facilities must be willing to implement new strategies that marry operational redesign, quality care, and cost-effective treatment. As payers increasingly favor outpatient strategies for patient management, inpatient facilities must develop effective strategies to shift inpatient care into ambulatory settings. This article presents a model, based on acute heart failure, that offers a solution that is fixed on process improvement techniques that levy positive economic impact.

Assessment of animal hosts of pathogenic Leptospira in northern Tanzania.

Leptospirosis is a zoonotic bacterial disease that affects more than one million people worldwide each year. Human infection is acquired through direct or indirect contact with the urine of an infected animal. A wide range of animals including rodents and livestock may shed Leptospira bacteria and act as a source of infection for people. In the Kilimanjaro Region of northern Tanzania, leptospirosis is an important cause of acute febrile illness, yet relatively little is known about animal hosts of Leptospira infection in this area. The roles of rodents and ruminant livestock in the epidemiology of leptospirosis were evaluated through two linked studies. A cross-sectional study of peri-domestic rodents performed in two districts with a high reported incidence of human leptospirosis found no evidence of Leptospira infection among rodent species trapped in and around randomly selected households. In contrast, pathogenic Leptospira infection was detected in 7.08% cattle (n = 452 [5.1-9.8%]), 1.20% goats (n = 167 [0.3-4.3%]) and 1.12% sheep (n = 89 [0.1-60.0%]) sampled in local slaughterhouses. Four Leptospira genotypes were detected in livestock. Two distinct clades of L. borgpetersenii were identified in cattle as well as a clade of novel secY sequences that showed only 95% identity to known Leptospira sequences. Identical L. kirschneri sequences were obtained from qPCR-positive kidney samples from cattle, sheep and goats. These results indicate that ruminant livestock are important hosts of Leptospira in northern Tanzania. Infected livestock may act as a source of Leptospira infection for people. Additional work is needed to understand the role of livestock in the maintenance and transmission of Leptospira infection in this region and to examine linkages between human and livestock infections.

Virtual Sculpting and 3D Printing for Young People with Disabilities.

The SHIVA project was designed to provide virtual sculpting tools for young people with complex disabilities, allowing them to engage with artistic and creative activities that they might otherwise never be able to access. Their creations are then physically built using 3D printing. To achieve this, the authors built a generic, accessible GUI and a suitable geometric modeling system and used these to produce two prototype modeling exercises. These tools were deployed in a school for students with complex disabilities and are now being used for a variety of educational and developmental purposes. This article presents the project's motivations, approach, and implementation details together with initial results, including 3D printed objects designed by young people with disabilities.

Elimination of medically unnecessary duplex venous scanning based on an established algorithm can result in significant cost savings under Medicare for the institution and the taxpayer.

OBJECTIVE: The utility of duplex venous scanning (DVS) for suspected deep venous thrombosis in the emergency department (ED) remains controversial. We aimed to measure potential cost savings and economic impact in our institution and nationally for unnecessary DVS in Medicare patients seen in the ED. METHODS: We have previously calculated that 15.3% of DVS studies can safely be avoided in patients with suspected deep venous thrombosis in our ED with adherence to our protocol. The Medicare database was queried for the number of DVS studies performed in the ED and charges/payments made in 2011. Cost savings at our institution and nationally by Medicare were computed with the 15.3% number. RESULTS: In the study period, 2087 DVS studies were performed in our ED across all payers; 572 Medicare patients had 249 (43%) bilateral and 323 (57%) unilateral studies. Annual savings at our institution, with use of our protocol, were estimated at $113,778. Eliminating unnecessary after-hours DVS for 306,307 Medicare beneficiaries would result in $5,285,090 savings annually. CONCLUSIONS: Increasing pressure for cost containment under a value-based payment model necessitates critical evaluation of resource utilization. Applying this schema for all noninvasive vascular tests is an opportunity for responsible management of finite resources, reducing wasteful care, and significant cost containment.

The Impact of Medical Student Participation in Emergency Medicine Patient Care on Departmental Press Ganey Scores.

INTRODUCTION: Press Ganey (PG) scores are used by public entities to gauge the quality of patient care from medical facilities in the United States. Academic health centers (AHCs) are charged with educating the new generation of doctors, but rely heavily on PG scores for their business operation. AHCs need to know what impact medical student involvement has on patient care and their PG scores. PURPOSE: We sought to identify the impact students have on emergency department (ED) PG scores related to overall visit and the treating physician's performance. METHODS: This was a retrospective, observational cohort study of discharged ED patients who completed PG satisfaction surveys at one academic, and one community-based ED. Outcomes were responses to questions about the overall visit assessment and doctor's care, measured on a five-point scale. We compared the distribution of responses for each question through proportions with 95% confidence intervals (CIs) stratified by medical student participation. For each question, we constructed a multivariable ordinal logistic regression model including medical student involvement and other independent variables known to affect PG scores. RESULTS: We analyzed 2,753 encounters, of which 259 (9.4%) had medical student involvement. For all questions, there were no appreciable differences in patient responses when stratifying by medical student involvement. In regression models, medical student involvement was not associated with PG score for any outcome, including overall rating of care (odds ratio [OR] 1.10, 95% CI [0.90-1.34]) or likelihood of recommending our EDs (OR 1.07, 95% CI [0.86-1.32]). Findings were similar when each ED was analyzed individually. CONCLUSION: We found that medical student involvement in patient care did not adversely impact ED PG scores in discharged patients. Neither overall scores nor physician-specific scores were impacted. Results were similar at both the academic medical center and the community teaching hospital at our institution.

Emergency department observation units and the older patient.

An increasing number of emergency departments (EDs) are providing extended care and monitoring of patients in ED observation units (EDOUs). EDOUs can be useful for older adults as an alternative to hospitalization and as a means of risk stratification for older adults with unclear presentations. They can also provide a period of therapeutic intervention and reassessment for older patients in whom the appropriateness and safety of immediate outpatient care are unclear. This article discusses the general characteristics of EDOUs, reviews appropriate entry and exclusion criteria for older adults in EDOUs, and discusses regulatory implications of observation status for patients with Medicare.