Community-based integrated tick management programs: cost and feasibility scenarios.

Numerous studies have assessed the efficacy of environmentally based control methods to suppress populations of the blacklegged tick (Ixodes scapularis Say), but few of these estimated the cost of control. We estimated costs for a range of tick control methods (including habitat management, deer exclusion or population reduction, broadcast of acaricides, and use of host-targeted acaricides) implemented singly or in combination and applied to a model community comprising 320 residential properties and parklands. Using the high end for cost ranges, tick control based on a single method was estimated to have mean annual costs per household in the model community ranging from $132 for treating only forest ecotone with a broadcast synthetic acaricide to kill host-seeking ticks (or $404 for treating all residential forested habitat) to >$2,000 for deployment of bait boxes (SELECT TCS) across all residential tick habitat to treat rodents topically with acaricide to kill infesting ticks. Combining different sets of multiple methods in an integrated tick management program placed the annual cost between $508 and 3,192 annually per household in the model community, underscoring the disconnect between what people in Lyme disease endemic areas say they are willing to pay for tick control (not more than $100-150 annually) and the actual costs for tick control. Additional barriers to implementing community-based tick management programs within residential communities are discussed.

Assessment of Drug Resistance during Phase 2b Clinical Trials of Presatovir in Adults Naturally Infected with Respiratory Syncytial Virus.

This study summarizes drug resistance analyses in 4 recent phase 2b trials of the respiratory syncytial virus (RSV) fusion inhibitor presatovir in naturally infected adults. Adult hematopoietic cell transplant (HCT) recipients, lung transplant recipients, or hospitalized patients with naturally acquired, laboratory-confirmed RSV infection were enrolled in 4 randomized, double-blind, placebo-controlled studies with study-specific presatovir dosing. Full-length RSV F sequences amplified from nasal swabs obtained at baseline and postbaseline were analyzed by population sequencing. Substitutions at RSV fusion inhibitor resistance-associated positions are reported. Genotypic analyses were performed on 233 presatovir-treated and 149 placebo-treated subjects. RSV F variant V127A was present in 8 subjects at baseline. Population sequencing detected treatment-emergent substitutions in 10/89 (11.2%) HCT recipients with upper and 6/29 (20.7%) with lower respiratory tract infection, 1/35 (2.9%) lung transplant recipients, and 1/80 (1.3%) hospitalized patients treated with presatovir; placebo-treated subjects had no emergent resistance-associated substitutions. Subjects with substitutions at resistance-associated positions had smaller decreases in viral load during treatment relative to those without, but they had similar clinical outcomes. Subject population type and dosing regimen may have influenced RSV resistance development during presatovir treatment. Subjects with genotypic resistance development had decreased virologic responses compared to those without genotypic resistance but had comparable clinical outcomes.

Drug Resistance Assessment Following Administration of Respiratory Syncytial Virus (RSV) Fusion Inhibitor Presatovir to Participants Experimentally Infected With RSV.

BACKGROUND: Presatovir is an oral respiratory syncytial virus (RSV) fusion inhibitor targeting RSV F protein. In a double-blind, placebo-controlled study in healthy adults experimentally infected with RSV (Memphis-37b), presatovir significantly reduced viral load and clinical disease severity in a dose-dependent manner. METHODS: Viral RNA from nasal wash samples was amplified and the F gene sequenced to monitor presatovir resistance. Effects of identified amino acid substitutions on in vitro susceptibility to presatovir, viral fitness, and clinical outcome were assessed. RESULTS: Twenty-eight treatment-emergent F substitutions were identified. Of these, 26 were tested in vitro; 2 were not due to lack of recombinant virus recovery. Ten substitutions did not affect presatovir susceptibility, and 16 substitutions reduced RSV susceptibility to presatovir (2.9- to 410-fold). No substitutions altered RSV susceptibility to palivizumab or ribavirin. Frequency of phenotypically resistant substitutions was higher with regimens containing lower presatovir dose and shorter treatment duration. Participants with phenotypic presatovir resistance had significantly higher nasal viral load area under the curve relative to those without, but substitutions did not significantly affect peak viral load or clinical manifestations of RSV disease. CONCLUSIONS: Emergence of presatovir-resistant RSV occurred during therapy but did not significantly affect clinical efficacy in participants with experimental RSV infection.

Availability and Nature of Commercial Tick Control Services in Three Lyme Disease Endemic States.

In an update of earlier surveys conducted in Connecticut and New Jersey in the mid-1990s, an online survey of private commercial pest control firms engaged in residential tick control showed that the application of synthetic acaricides continues to be the primary method of control used. The carbamate and organophospate acaricides, previously the most commonly used against ticks, have given way to synthetic pyrethroids and, to a lesser extent, the use of natural product/organic acaricides. Typical costs for a single acaricide application today ($100-$200 for a 1 acre [0.4 ha] property) remain similar to those reported from the earlier surveys, although the frequency of applications and, therefore, also the overall annual cost has increased. The application habitats within residential properties, life stages targeted, and application equipment used have not changed appreciably since the mid-1990s. While most survey respondents expressed knowledge of natural product acaricides and Damminix Tick Tubes, many reported that they either did not employ or knew very little about other alternative tick control methods (including entomopathogenic fungus and topical application of acaricides to tick hosts via 4-Poster deer treatment stations or Select TCS rodent bait boxes). This suggests either a failure to adequately inform the pest management industry and their potential client base of the availability of alternate methods, and/or industry concerns about cost and effectiveness of the alternatives.

Physical examination tests and imaging studies based on arthroscopic assessment of the long head of biceps tendon are invalid.

PURPOSE: The aim of this study was to evaluate whether glenohumeral arthroscopy is an appropriate gold standard for the diagnosis of long head of biceps (LHB) tendon pathology. The objectives were to evaluate whether the length of tendon that can be seen at arthroscopy allows visualisation of areas of predilection of pathology and also to determine the rates of missed diagnoses at arthroscopy when compared to an open approach. METHODS: A systematic review of cadaveric and clinical studies was performed. The search strategy was applied to MEDLINE, PubMed and Google Scholar databases. All relevant articles were included. Critical appraisal of clinical studies was performed using a validated quality assessment scale. RESULTS: Five articles were identified for inclusion in the review. This included both clinical and cadaveric studies. The overall population comprised 18 cadaveric specimens and 575 patients. Out of the five included studies, three reported the length of LHB tendon visualised during arthroscopy and four reported the rate of missed LHB diagnosis. Cadaveric studies showed that the use of a hook probe allowed arthroscopic visualisation of between 34 and 48 % of the overall length of the LHB. In the clinical series, the rate of missed diagnoses at arthroscopy when compared to open exploration ranged between 33 and 49 %. CONCLUSIONS: Arthroscopy allows visualisation of only a small part of the extra-articular LHB tendon. This leads to a high rate of missed pathology in the distal part of the tendon. Published figures for sensitivities and specificities of common physical examination and imaging tests for LHB pathology that are based on arthroscopy as the gold standard are therefore invalid. In clinical practice, it is important to note that a "negative" arthroscopic assessment does not exclude a lesion of the LHB tendon as this technique does not allow visualisation of common sites of distal pathology. LEVEL OF EVIDENCE: IV.

The cost of major lower limb amputation: a 12-year experience.

BACKGROUND: The amputee population is elderly, has significant medical co-morbidities and perioperative mortality leading to high financial implications. Commonly used outcomes in the literature are survival, prosthetic use and mobility. OBJECTIVES: Our study aims to share our 12-year experience of amputee care, concentrating on perioperative mortality and patient rehabilitation. STUDY DESIGN: Observational study in the form of a retrospective case series. METHODS: In total, 130 amputations, performed between January 1998 and December 2009, were followed up for a mean of three and a half years and analyzed for demographics, vascular history, operation details, prosthetic use, mobility and mortality. RESULTS: The population was 59.2% male, had a mean age of 73 and the most common indication for amputation was critical ischaemia (78.5%). The average length of acute inpatient stay was 63 days with a 30-day mortality rate of 15.3% and inpatient mortality of 29.3%. In total, 63.3% of patients were issued with a prosthesis with 48.2% of all patients achieving at least indoor mobility, transtibial (49.9%) rehabilitated better than transfemoral amputees (24.3%). CONCLUSIONS: Our data support the urgent need for action to improve perioperative mortality in the amputee population, with the added advantage of reducing its financial impact. Clinical relevance Our study gives an overview of the clinical journey taken by a 12-year amputee population. By following this cohort from initial procedure through to rehabilitation or mortality we provide the reader with a valuable insight into the difficulties of managing this population and the likely outcomes for these patients.