Real-world treatment preferences among health care providers in the United States in selecting disease modifying therapies for patients with multiple sclerosis: a discrete choice experiment.

AIMS: Health care providers (HCPs) treating multiple sclerosis (MS) in clinical practice have numerous disease-modifying therapies (DMTs) to consider when evaluating treatment options. This study assessed the treatment preferences of HCPs in the United States, both direct (explicit) and derived (explicit and implicit), when selecting MS DMTs based on clinical and logistical treatment attributes. MATERIALS AND METHODS: A 45-minute web-enabled questionnaire was administered to HCPs who manage patients with MS to assess the importance of treatment attributes. HCPs were recruited through an online panel. This study examined treatment attributes relevant to treatment decisions in MS, with a focus on the burden to HCPs and their staff, as well as HCP attitudes toward various aspects of MS care such as diagnosis, treatment prioritization, and ease of initiating or switching DMTs. The study also employed a discrete choice experiment (DCE) to assess direct and derived treatment preferences. RESULTS: The study recruited 145 HCPs. Direct assessments (a score of greater than 7.0 was considered important) suggested that safety (mean importance rating = 7.8/9) and relative risk reduction in relapses (7.6/9) and disability progression (7.5/9) were most important when selecting DMTs. In contrast, derived importance from the DCE (higher points corresponding to greater importance) suggested that logistical attributes such as dose frequency (mean relative attribute importance = 17.5%), dose titration (10.3%), formulation (9.4%), and volume of calls (9.1%) were important considerations, along with efficacy (16.5%), safety (9.8%), and gastrointestinal tolerability (9.4%). LIMITATIONS: This study may have been subject to selection bias due to the application of eligibility criteria, the convenient sampling recruitment methodology, and recruitment of HCPs with internet access. CONCLUSION: In the direct assessment, clinical attributes were chosen as the most important treatment attributes by HCPs. However, in the DCE, derived treatment decisions rated logistical attributes as also being as important in treatment choice.

In this study, researchers aimed to understand what multiple sclerosis (MS) neurologists, nurse practitioners, and physician assistants think is most important when choosing medicines for their patients. They surveyed 145 health care providers (HCPs) in the United States for this study. The HCPs reported that safety and reducing the risk of relapses and disability were most important when selecting medicines. Additionally, the researchers used a method called a discrete choice experiment to determine the relative importance of medication characteristics to HCPs. They found that additional factors, such as how often the medicine needs to be taken, how it is given, and how easy it is to use, were also very important. The study may not represent the opinions of all HCPs due to the number of participants and participation criteria.

Identifying primary and secondary MLH1 epimutation carriers displaying low-level constitutional MLH1 methylation using droplet digital PCR and genome-wide DNA methylation profiling of colorectal cancers.

BACKGROUND: MLH1 epimutation is characterised by constitutional monoallelic MLH1 promoter hypermethylation, which can cause colorectal cancer (CRC). Tumour molecular profiles of MLH1 epimutation CRCs were used to classify germline MLH1 promoter variants of uncertain significance and MLH1 methylated early-onset CRCs (EOCRCs). Genome-wide DNA methylation and somatic mutational profiles of tumours from two germline MLH1: c.-11C > T and one MLH1: c.-[28A > G; 7C > T] carriers and three MLH1 methylated EOCRCs (< 45 years) were compared with 38 reference CRCs. Methylation-sensitive droplet digital PCR (ddPCR) was used to detect mosaic MLH1 methylation in blood, normal mucosa and buccal DNA. RESULTS: Genome-wide methylation-based Consensus Clustering identified four clusters where the tumour methylation profiles of germline MLH1: c.-11C > T carriers and MLH1 methylated EOCRCs clustered with the constitutional MLH1 epimutation CRCs but not with the sporadic MLH1 methylated CRCs. Furthermore, monoallelic MLH1 methylation and APC promoter hypermethylation in tumour were observed in both MLH1 epimutation and germline MLH1: c.-11C > T carriers and MLH1 methylated EOCRCs. Mosaic constitutional MLH1 methylation in MLH1: c.-11C > T carriers and 1 of 3 MLH1 methylated EOCRCs was identified by methylation-sensitive ddPCR. CONCLUSIONS: Mosaic MLH1 epimutation underlies the CRC aetiology in MLH1: c.-11C > T germline carriers and a subset of MLH1 methylated EOCRCs. Tumour profiling and ultra-sensitive ddPCR methylation testing can be used to identify mosaic MLH1 epimutation carriers.

A tumor focused approach to resolving the etiology of DNA mismatch repair deficient tumors classified as suspected Lynch syndrome.

Routine screening of tumors for DNA mismatch repair (MMR) deficiency (dMMR) in colorectal (CRC), endometrial (EC) and sebaceous skin (SST) tumors leads to a significant proportion of unresolved cases classified as suspected Lynch syndrome (SLS). SLS cases (n = 135) were recruited from Family Cancer Clinics across Australia and New Zealand. Targeted panel sequencing was performed on tumor (n = 137; 80×CRCs, 33×ECs and 24xSSTs) and matched blood-derived DNA to assess for microsatellite instability status, tumor mutation burden, COSMIC tumor mutational signatures and to identify germline and somatic MMR gene variants. MMR immunohistochemistry (IHC) and MLH1 promoter methylation were repeated. In total, 86.9% of the 137 SLS tumors could be resolved into established subtypes. For 22.6% of these resolved SLS cases, primary MLH1 epimutations (2.2%) as well as previously undetected germline MMR pathogenic variants (1.5%), tumor MLH1 methylation (13.1%) or false positive dMMR IHC (5.8%) results were identified. Double somatic MMR gene mutations were the major cause of dMMR identified across each tumor type (73.9% of resolved cases, 64.2% overall, 70% of CRC, 45.5% of ECs and 70.8% of SSTs). The unresolved SLS tumors (13.1%) comprised tumors with only a single somatic (7.3%) or no somatic (5.8%) MMR gene mutations. A tumor-focused testing approach reclassified 86.9% of SLS into Lynch syndrome, sporadic dMMR or MMR-proficient cases. These findings support the incorporation of tumor sequencing and alternate MLH1 methylation assays into clinical diagnostics to reduce the number of SLS patients and provide more appropriate surveillance and screening recommendations.

A tumor focused approach to resolving the etiology of DNA mismatch repair deficient tumors classified as suspected Lynch syndrome.

Routine screening of tumors for DNA mismatch repair (MMR) deficiency (dMMR) in colorectal (CRC), endometrial (EC) and sebaceous skin (SST) tumors leads to a significant proportion of unresolved cases classified as suspected Lynch syndrome (SLS). SLS cases (n=135) were recruited from Family Cancer Clinics across Australia and New Zealand. Targeted panel sequencing was performed on tumor (n=137; 80xCRCs, 33xECs and 24xSSTs) and matched blood-derived DNA to assess for microsatellite instability status, tumor mutation burden, COSMIC tumor mutational signatures and to identify germline and somatic MMR gene variants. MMR immunohistochemistry (IHC) and MLH1 promoter methylation were repeated. In total, 86.9% of the 137 SLS tumors could be resolved into established subtypes. For 22.6% of these resolved SLS cases, primary MLH1 epimutations (2.2%) as well as previously undetected germline MMR pathogenic variants (1.5%), tumor MLH1 methylation (13.1%) or false positive dMMR IHC (5.8%) results were identified. Double somatic MMR gene mutations were the major cause of dMMR identified across each tumor type (73.9% of resolved cases, 64.2% overall, 70% of CRC, 45.5% of ECs and 70.8% of SSTs). The unresolved SLS tumors (13.1%) comprised tumors with only a single somatic (7.3%) or no somatic (5.8%) MMR gene mutations. A tumor-focused testing approach reclassified 86.9% of SLS into Lynch syndrome, sporadic dMMR or MMR-proficient cases. These findings support the incorporation of tumor sequencing and alternate MLH1 methylation assays into clinical diagnostics to reduce the number of SLS patients and provide more appropriate surveillance and screening recommendations.

Mainstream genetic testing for high-grade ovarian, tubal and peritoneal cancers: A tertiary referral centre experience.

BACKGROUND: Fifteen percent of ovarian, tubal, and peritoneal (OTP) invasive epithelial cancers are linked to an underlying heritable pathogenic variant (PV) in the BRCA1/2 cancer susceptibility genes. Identifying a PV has management implications for an affected individual and relatives. Cancer team-facilitated genetic testing (mainstreaming) aims to provide equitable systematic access to genetic testing for appropriate patients. AIM: To evaluate a multi-disciplinary team (MDT)-led mainstream germline genetic testing program for OTP cancer at a tertiary referral centre. MATERIALS AND METHODS: We conducted a retrospective review of our MDT-led mainstream genetic testing program initiated in June 2017. We included all patients diagnosed with OTP cancer registered with the hospital gynaecological oncology MDT from program initiation to December 2020. Patients were considered eligible for testing if they were diagnosed with a high-grade epithelial OTP AND ≤70 years, OR if >70 with a first/second degree relative with breast and/or ovarian cancer OR Jewish ancestry. RESULTS: Of 205 women diagnosed with high-grade epithelial OTP cancer, 140 were eligible for mainstreaming. Eight-five percent were mainstreamed, with the gynae-oncologists facilitating 64.5% of tests. The overall PV detection rate in BRCA1/2 was 10.1% (BRCA1 n = 9, BRCA2 n = 3). The median turnaround time (TAT) was 44.5 days (range 16-118). All women with PV were referred to the Familial Cancer Service for further assessment and five (of six eligible; 83%) were subsequently treated with polyadenosine diphosphate ribose polymerase inhibitors. Cascade testing was undertaken in 75% of families with a mean of three relatives tested per proband. CONCLUSION: Mainstreamed genetic testing is feasible, with an acceptable TAT, ensuring adequate opportunity to inform treatment decisions. Tumour testing and inclusion of moderate-risk cancer predisposition genes in mainstreaming represent potential pathways that will require further exploration.

Treatment and Outcomes of Tusk Fractures in Managed African Savanna and Asian Elephants (Loxodonta africana and Elephas maximus) across Five Continents.

Elephant tusk fractures are a clinical challenge that can impact the overall health of the animal, particularly when they result in pulp exposure. An international survey was sent to veterinarians to understand individual fracture characteristics and management strategies as they relate to outcomes, with the goal of better informing treatment procedures. The data set consisted of 79 fractures from 64 elephants (including Asian and African males and females), 44.3% of which were Class III fractures with pulpal involvement. Of this subset, pulp canal exposures of >0.5 cm were 23.8-fold more likely to develop pulpitis than fractures with <0.5 cm exposed, though canal size did not impact healing versus extraction outcome. Odds ratios showed that treatments including endodontics were 12.0-fold more likely to heal than tusks treated exclusively with medical management, though no association was observed in reducing the risk of pulpitis. Further, pulpitis was 7.58-fold more likely to develop when tap water was used to rinse exposed pulpal tissue; a finding that merits further investigation. The use of endodontic treatment versus medical management alone was significantly associated with improved recovery outcomes (i.e., reduced risk of extraction) in tusk fractures with pulpal involvement.

ACUTE HEMORRHAGIC DISEASE DUE TO ELEPHANT ENDOTHELIOTROPIC HERPESVIRUS 3A INFECTION IN FIVE AFRICAN ELEPHANTS (LOXODONTA AFRICANA) AT ONE NORTH AMERICAN ZOOLOGICAL INSTITUTION.

Acute hemorrhagic disease caused by elephant endotheliotropic herpesvirus (EEHV) infection is well recognized as a major threat to young Asian elephants (Elephas maximus) but has been less frequently documented in African elephants (Loxodonta africana). This report describes five sequential cases of EEHV3A infection in African elephants in managed care at one institution. All elephants developed disease within a 4-mo period. The first two cases were 6.5- and 7.5-yr-old females that presented with depressed mentation, anorexia, hematuria, and diarrhea. Both elephants died within 48-72 hr of the onset of illness despite treatment. Postmortem findings included widespread edema, ascites, and extensive petechiae and ecchymoses on the heart, liver, and spleen and within the gastrointestinal and urogenital tracts. Histologic examination identified disseminated vascular necrosis with edema, hemorrhage, and rare endothelial cell intranuclear inclusions typical of herpesvirus in multiple organs. The third and fourth cases were a 13-yr-old male and a 12-yr-old female that presented with minimal to no clinical signs, but with marked changes in hematologic parameters and high viremia detected by quantitative polymerase chain reaction (qPCR). Both elephants survived the infection with early and aggressive treatment. The fifth case was a 37-yr-old female that presented with lethargy and a decreased appetite. Low viremia was detected by qPCR, and mild to moderate hematologic changes were noted. Early treatment resulted in a successful outcome. This case series documents the first known reports of clinical disease and fatality associated with EEHV3A in African elephants.

CONGENITAL HYPOTHYROIDISM IN A BORNEAN ORANGUTAN (PONGO PYGMAEUS) AND A SUMATRAN ORANGUTAN (PONGO ABELII).

Congenital hypothyroidism (CH) in humans is most commonly caused by disruption of thyroid gland development (dysgenesis) or an inherited defect in thyroid hormone biosynthesis (dyshormonogenesis). CH has not been previously documented in great apes. This report describes the clinical presentation, diagnosis, and treatment of CH in a 9-mo-old male Bornean orangutan (Pongo pygmaeus) and a 6-wk-old female Sumatran orangutan (Pongo abelii). Primary CH due to thyroid dysgenesis was confirmed in the Bornean orangutan using sonography and radioisotope scintigraphy. Although commercial thyroid immunoassays are not validated for use in orangutans, in comparison to age-matched controls, thyroid-stimulating hormone level was markedly elevated, and serum thyroxine (T4) and free T4 levels were markedly decreased in both cases. Oral supplementation with levothyroxine sodium resulted in noticeable clinical improvement in both orangutans within 30 days of initiating treatment.

NAÏVE-POOLED PHARMACOKINETICS OF CEFTIOFUR CRYSTALLINE FREE ACID AFTER SINGLE INTRAMUSCULAR ADMINISTRATION IN SMOOTH DOGFISH (MUSTELUS CANIS).

Pharmacokinetics study of ceftiofur crystalline free acid (CCFA) was conducted in 14 adult captive smooth dogfish (Mustelus canis). A single dose of CCFA at 6.6 mg/kg was administered intramuscularly. Blood samples were collected prior to treatment and at 1, 2, 6, 12, 24, 32, 48, 72, 96, 120, 144, and 168 hr posttreatment. Naïve pooling of data from four sharks was used to generate the average plasma drug concentration at each time point. After concluding the study, additional blood samples were opportunistically collected from five randomly selected sharks at 1,920 hr. Plasma ceftiofur and desfuroylceftiofur metabolite concentrations were determined using reversed-phase high performance liquid chromatography (HPLC). Pharmacokinetic analysis was performed using a noncompartmental technique. Peak plasma concentration (Cmax) was 3.75 µg/ml with a time to Cmax (Tmax) of 96 hr. Ceftiofur plasma concentrations were maintained above 2 µg/ml for at least 168 hr and were still quantifiable at 1,920 hr.

SURGICAL MANAGEMENT OF UTERINE LESIONS IN TWO CAPTIVE ORANGUTANS ( PONGO SPP.).

Uterine lesions in two orangutans were effectively managed with surgical intervention. A 26-year-old hybrid orangutan ( Pongo spp.) was diagnosed with uterine adenomyosis based on advanced imaging. Histologic evaluation identified multifocal myometrial endometriosis, a variant of adenomyosis. A 27-year-old Bornean orangutan ( Pongo pygmaeus) was diagnosed with a focal uterine fibroid based on histologic examination. The animals were housed at separate institutions and initially presented with dysmenorrhea and menorrhagia. Both animals were treated intermittently for episodes of dysmenorrhea, with recurrence of clinical signs after each treatment. Due to the lack of consistent response to medical management, an ovariohysterectomy in the hybrid orangutan and a myomectomy in the Bornean orangutan were performed and resulted in complete resolution of clinical signs. Surgical management of adenomyosis and neoplasia has previously been reported in nonhuman primates. These cases are the first known documentation of surgical management of multifocal myometrial endometriosis and a fibroid in orangutans.

Assessing landscape and contaminant point-sources as spatial determinants of water quality in the Vermilion River System, Ontario, Canada.

The Vermilion River and major tributaries (VRMT) are located in the Vermilion watershed (4272 km2) in north-central Ontario, Canada. This watershed not only is dominated by natural land-cover but also has a legacy of mining and other development activities. The VRMT receive various point (e.g., sewage effluent) and non-point (e.g., mining activity runoff) inputs, in addition to flow regulation features. Further development in the Vermilion watershed has been proposed, raising concerns about cumulative impacts to ecosystem health in the VRMT. Due to the lack of historical assessments on riverine-health in the VRMT, a comprehensive suite of water quality parameters was collected monthly at 28 sites during the ice-free period of 2013 and 2014. Canadian water quality guidelines and objectives were not met by an assortment of water quality parameters, including nutrients and metals. This demonstrates that the VRMT is an impacted system with several pollution hotspots, particularly downstream of wastewater treatment facilities. Water quality throughout the river system appeared to be influenced by three distinct land-cover categories: forest, barren, and agriculture. Three spatial pathway models (geographical, topographical, and river network) were employed to assess the complex interactions between spatial pathways, stressors, and water quality condition. Topographical landscape analyses were performed at five different scales, where the strongest relationships between water quality and land-use occurred at the catchment scale. Sites on the main stem of Junction Creek, a tributary impacted by industrial and urban development, had above average concentrations for the majority of water quality parameters measured, including metals and nitrogen. The river network pathway (i.e., asymmetric eigenvector map (AEM)) and topographical feature (i.e., catchment land-use) models explained most of the variation in water quality (62.2%), indicating that they may be useful tools in assessing the spatial determinants of water quality decline.

Progressive multifocal leukoencephalopathy in a patient without apparent immunosuppression.

Progressive multifocal leukoencephalopathy (PML) is a viral demyelinating disease due to the reactivation of the JC virus (JCV), which usually occurs in the context of immunosuppression in HIV infection, malignancy, or in patients on disease modifying therapy for autoimmune diseases, such as multiple sclerosis (MS) and Crohn's disease. Notably, there is growing recognition that PML can occur in patients with transient immune dysfunction. Here, we present a case of a 55-year-old man without history of immunosuppression or evidence of ICL who was diagnosed with PML on brain biopsy. We will discuss the potential etiologies of mild and transient immunosuppression that can lead to PML with non-apparent immunosuppression.

Responsibilities of Health Care Professionals in Counseling and Educating Patients With Incurable Neurological Diseases Regarding "Stem Cell Tourism": Caveat Emptor.

"Stem cell tourism" is a rising Internet-based industry that aims to offer unproven procedures to patients with incurable diseases. This unregulated activity is reaching the neurologist's office as well as across the world, as patients request information or clearance for such procedures. Herein, we posit the need for medical societies and licensing boards to bring this issue to the forefront of neurology because it has the potential to affect patient care with risk of morbidity and mortality, as well as to undermine public confidence in legitimate stem cell research for incurable neurological diseases such as multiple sclerosis and amyotrophic lateral sclerosis.

Comparisons of childhood trauma, alexithymia, and defensive styles in patients with psychogenic non-epileptic seizures vs. epilepsy: Implications for the etiology of conversion disorder.

BACKGROUND: It has been theorized that conversion disorder is the result of emotion that cannot be experienced consciously as feeling states or put into words (i.e., alexithymia), but there is little confirming empirical evidence. We sought to characterize subjects with conversion disorder compared to subjects with a distinct medical illness, using the model of psychogenic non-epileptic seizures (PNES) vs. epilepsy (ES), on measures of childhood traumatic experience, alexithymia and maturity of psychological defensive strategies. METHODS: All subjects admitted to the Epilepsy Monitoring Unit of the University of Cincinnati Medical Center were offered self-report questionnaires (Childhood Trauma Questionnaire, Toronto Alexithymia Scale-20 and Response Evaluation Measure-71) at the outset of evaluation. Diagnosis of each subject was confirmed by video-EEG and we compared subjects with PNES to those with ES on these measures. RESULTS: 82 subjects had ES AND 96 had PNES. Those with PNES were significantly more likely to have experienced childhood trauma in all domains (p=.005 to p=.05), and were significantly more likely to have alexithymia (p=.0267). There was a significant difference in the capacity to identify feelings, and a trend towards significance in capacity to describe feelings. There were no differences in defensive styles between the two groups. CONCLUSIONS: PNES diagnosis was associated with female sex, higher alexithymia scores and higher rates of childhood trauma, but not with differences in defensive styles compared to ES. These findings add empirical evidence for theories regarding the cause of conversion disorder and may aid in the design of prospective treatment trials in patients with conversion disorder.

Hematologic, plasma biochemistry, and select nutrient values in captive smooth dogfish (Mustelus canis).

The Indianapolis Zoo maintains a large collection of smooth dogfish (Mustelus canis). During the first several years of captivity, there was a period of high mortality in adult, wild-caught sharks in the collection. Smooth dogfish with superficial abrasions would rapidly succumb to infection and death, regardless of the treatment approach. Although the sharks did successfully produce viable offspring, there was an elevated pup mortality rate, with 0% of the pups reaching 1 yr of age during the same period of high mortality in adult sharks. This poor response to captivity prompted interest in the physiologic response of these animals to illness. The objective of this investigation was to establish a preliminary data set of hematologic and plasma chemistry reference intervals, along with select nutrient parameters specific to wild-caught adults maintained in prolonged captivity (i.e., greater than 22 mo). Blood samples were collected from 20 clinically healthy, male (n = 10) and female (n = 10) dogfish sharks at the Oceans facility at the Indianapolis Zoo. Although gender differences in mortality rate were not apparent, complete blood cell counts, plasma biochemical profiles, and select nutrient analyses were performed and analyzed accordingly. Statistically significant differences (P < or = 0.05) specific to sex were determined for parameters including packed cell volume (PCV), absolute and relative fine eosinophilic granulocytes, relative percentage of coarse eosinophilic granulocytes, globulins, the albumin/globulin ratio, total protein, phosphorus, iron, selenium and copper. White blood cell counts appear to be lower in this species compared to other captive elasmobranchs. Further research into appropriate hematology standards including nutritional parameters appears warranted.

Regional reference variation provides ecologically meaningful protection criteria for northern world heritage site.

Unprecedented rates of resource development and climate change at northern latitudes coupled with a lack of baseline information limits our ability to set ecologically meaningful criteria needed to protect these inherently sensitive ecosystems. We surveyed water and sediment chemistry, community composition of benthic algae and invertebrates and fish, and condition of a sentinel fish species, slimy sculpin (Cottus cognatus), in 2 rivers adjacent to metal mines and in 20 reference rivers in the headwaters of a World Heritage Site, the South Nahanni River Basin, NWT, Canada. The normal range (i.e., mean ± 2 standard deviations) of biological conditions in regional reference sites (grouped by community type) were used to set ecologically meaningful effect sizes. These effect sizes were used in noncentral hypotheses tests to assess the ecological condition of potentially impaired sites. Significant impairments at sites influenced by current and historical mining activity were indicative of mild enrichment (e.g., increased benthic abundance and sculpin condition) and bioaccumulation of metals (e.g., increased concentrations of Cu and Fe in muscle tissue of sculpin). Comparisons between our regional reference study and a concurrent upstream­downstream study showed that the sensitivity of biological endpoints was typically related to the impairment criteria used and not to the type of study design. Concentrations of metals such as Al, Cu, and Fe in river water at reference sites were above federal and regional guidelines, suggesting that these guidelines are not appropriate for the metal-rich headwaters of the South Nahanni River. The ephemerellid mayflies Drunella spinifera and Ephemerella maculata were present in 4 of our study sites; their occurrence had not previously been documented in the Yukon or Northwest Territories. Our results confirmed that the lack of baseline information on the physiochemical and biological composition of northern rivers is hampering our ability to evaluate changes in these understudied ecosystems. However, the use of noncentral hypotheses tests based on empirically derived effect sizes enabled us to develop ecologically meaningful protection criteria, maintain statistical rigor, and provide probabilities of impairment that can be used directly in risk assessment.

Phaeohyphomycosis of the carapace in an Aldabra tortoise (Geochelone gigantea).

An adult male Aldabra tortoise (Geochelone gigantea) presented with a deep flaking area of the carapace, and histologic examination of biopsies from this area revealed phaeohyphomycosis of the superficial keratinized layers. The disease progressed rapidly and spread to numerous sites on the carapace. After several weeks of regular debridement, deep bone involvement was evident and was confirmed through histologic examination. Fungal culture was attempted but was unsuccessful at isolating the infectious agent. Polymerase chain reaction analysis of extracted DNA from the fixed tissue block identified the fungus as Exophiala oligosperma. Initial treatment included weekly debridement and oral and topical antifungal agents. A nuclear scintigraphy bone scan was performed to determine the extent and status of the infection. Multiple foci of uptake of the radiopharmaceutical marker were present within the carapace, indicating active lesions. The tortoise was maintained on oral antifungal treatment, and lesions resolved over several months. A repeat bone scan performed 1 yr after initial presentation showed reduction in marker uptake, indicating a response to treatment in the deeper lesions. Phaeohyphomycosis should be considered as a differential diagnosis for cases of shell lesions in chelonians.

A multitrophic approach to monitoring the effects of metal mining in otherwise pristine and ecologically sensitive rivers in northern Canada.

It is not known if current chemical and biological monitoring methods are appropriate for assessing the impacts of growing industrial development on ecologically sensitive northern waters. We used a multitrophic level approach to evaluate current monitoring methods and to determine whether metal-mining activities had affected 2 otherwise pristine rivers that flow into the South Nahanni River, Northwest Territories, a World Heritage Site. We compared upstream reference conditions in the rivers to sites downstream and further downstream of mines. The endpoints we evaluated included concentrations of metals in river water, sediments, and liver and flesh of slimy sculpin (Cottus cognatus); benthic algal and macroinvertebrate abundance, richness, diversity, and community composition; and various slimy sculpin measures, our sentinel forage fish species. Elevated concentrations of copper and iron in liver tissue of sculpin from the Flat River were associated with high concentrations of mine-derived iron in river water and copper in sediments that were above national guidelines. In addition, sites downstream of the mine on the Flat River had increased algal abundances and altered benthic macroinvertebrate communities, whereas the sites downstream of the mine on Prairie Creek had increased benthic macroinvertebrate taxa richness and improved sculpin condition. Biological differences in both rivers were consistent with mild enrichment of the rivers downstream of current and historical mining activity. We recommend that monitoring in these northern rivers focus on indicators in epilithon and benthic macroinvertebrate communities due to their responsiveness and as alternatives to lethal fish sampling in habitats with low fish abundance. We also recommend monitoring of metal burdens in periphyton and benthic invertebrates for assessment of exposure to mine effluent and causal association. Although the effects of mining activities on riverine biota currently are limited, our results show that there is potential for effects to occur with proposed growth in mining activities.

Deep fungal dermatitis in three inland bearded dragons (Pogona vitticeps) caused by the Chrysosporium anamorph of Nannizziopsis vriesii.

The Chrysosporium anamorph of Nannizziopsis vriesii (CANV), a keratinophilic fungus that naturally and experimentally causes severe and often fatal dermatitis in multiple reptile species, was isolated in pure culture from skin samples of three inland bearded dragons (Pogona vitticeps) with deep granulomatous dermatomycosis. The first animal presented with a focal maxillary swelling involving the skin and gingiva. This lizard died while undergoing itraconazole and topical miconazole therapy. The second presented with focally extensive discoloration and thickening of the skin of the ventrum and was euthanized after 10 weeks of itraconazole therapy. A third lizard presented with hyperkeratotic exudative dermatitis on a markedly swollen forelimb. Amputation and itraconazole therapy resulted in a clinical cure. Histopathology of tissue biopsies in all cases demonstrated granulomatous dermatitis with intralesional hyphae morphologically consistent with those produced by the CANV. The second lizard also had granulomatous hepatitis with intralesional hyphae. Evidence in this report suggests that the CANV is the etiologic agent of an emerging condition in captive bearded dragons that has been called 'yellow fungus disease'.