Prevalence and distribution of Anaplasma phagocytophilum in ticks collected from dogs in the United Kingdom.

BACKGROUND: Anaplasma phagocytophilum is the etiological agent of canine granulocytic anaplasmosis in dogs and causes human granulocytic anaplasmosis (HGA). Tick-borne anaplasmosis has been recognised as an emerging zoonotic health concern worldwide. The aim of the present study was to determine the prevalence of A. phagocytophilum in ticks collected from dogs in the UK and map its distribution. Routine surveillance of tick-borne disease is essential as part of a "One Health" approach to infectious disease management. METHODS: Tick DNA samples collected in 2015 as part of a large-scale tick surveillance programme were analysed using a previously validated diagnostic quantitative PCR for A. phagocytophilum. RESULTS: PCR analysis indicated that 138 out of 2994 tick DNA samples analysed were positive for A. phagocytophilum, a prevalence of 4.6% (95% CI: 3.89-5.42). Among these 138 tick DNA samples, 131 were from Ixodes ricinus, six were from Ixodes hexagonus and one was from Ixodes canisuga. Three of the I. ricinus tick DNA samples positive for A. phagocytophilum DNA were also positive for Borrelia spp. DNA and one was positive for Babesia spp. DNA, indicating co-infection. The ticks positive for the pathogen DNA were found widely distributed throughout the UK. CONCLUSIONS: These data provide important information on the prevalence and wide distribution of A. phagocytophilum in ticks infesting dogs within the UK.

Quality of Care in Hip Fracture Patients: The Relationship Between Adherence to National Standards and Improved Outcomes.

BACKGROUND: Optimizing the perioperative care of patients with a hip fracture is a key health-care priority. We aimed to determine whether adherence to the Scottish Standards of Care for Hip Fracture Patients (SSCHFP) was associated with improved patient outcomes. METHODS: In this retrospective cohort study of prospectively collected data from the Scottish National Hip Fracture Audit, we assessed adherence to the SSCHFP in 21 Scottish hospitals over a 9-month period in 2014 and examined the effect of the guidelines on 30 and 120-day mortality, length of hospital stay, and discharge destination. RESULTS: A total of 1,162 patients who were ≥50 years old and admitted with a hip fracture were included. There was a significant association between low adherence to the SSCHFP and increased mortality at 30 and 120 days (odds ratio [OR], 3.58 [95% confidence interval (CI), 1.75 to 7.32; p < 0.001] and 2.01 [95% CI, 1.28 to 3.12; p = 0.003], respectively). Low adherence was associated with a reduced likelihood of a short length of stay (OR, 0.58; 95% CI, 0.42 to 0.78; p < 0.0001), but increased odds of discharge to a high-care setting (OR, 1.63; 95% CI, 1.12 to 2.36; p = 0.01). Early physiotherapy input and occupational therapy input were associated with a reduced likelihood of discharge to a high-care setting (OR, 0.64 [95% CI, 0.44 to 0.98; p = 0.04] and 0.34 [95% CI, 0.23 to 0.48; p <0.001], respectively). CONCLUSIONS: Adherence to the SSCHFP is associated with better patient outcomes. These findings confirm the clinical utility of the SSCHFP and support their use as a benchmarking tool to improve quality of care for hip fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Construct validity of the Wechsler Intelligence Scale for Children - Fourth UK Edition with a referred Irish sample: Wechsler and Cattell-Horn-Carroll model comparisons with 15 subtests.

BACKGROUND: Irish educational psychologists frequently use the Wechsler Intelligence Scale for Children - Fourth UK Edition (WISC-IVUK ; Wechsler, 2004, Wechsler Intelligence Scale for Children-Fourth UK Edition, London, UK, Harcourt Assessment) in clinical assessments of children with learning difficulties. Unfortunately, reliability and validity studies of the WISC-IVUK standardization sample have not yet been reported. Watkins et al. (2013, International Journal of School and Educational Psychology, 1, 102) found support for a bifactor structure with a large sample (N = 794) of Irish children who were administered the 10 WISC-IVUK core subtests in clinical assessments of learning difficulties and dominance of general intelligence. Because only 10 subtests were available, Cattell-Horn-Carroll (CHC; McGrew, 1997, 2005, Contemporary intellectual assessment: Theories, tests, and issues, New York, NY: Guilford; Schneider & McGrew, 2012, Contemporary intellectual assessment: Theories, tests, and issues, New York, NY, Guilford Press) models could not be tested and compared. AIM, SAMPLE AND METHOD: The present study utilized confirmatory factor analyses to test the latent factor structure of the WISC-IVUK with a sample of 245 Irish children administered all 15 WISC-IVUK subtests in evaluations assessing learning difficulties in order to examine CHC- and Wechsler-based models. One through five, oblique first-order factor models and higher order versus bifactor models were examined and compared using CFA. RESULTS: Meaningful differences in fit statistics were not observed between the Wechsler and CHC representations of higher-order or bifactor models. In all four structures, general intelligence accounted for the largest portions of explained common variance, whereas group factors accounted for small to miniscule portions of explained common variance. Omega-hierarchical subscale coefficients indicated that unit-weighted composites that would be generated by WISC-IVUK group factors (Wechsler or CHC) would contain little unique variance and thus be of little value. CONCLUSION: These results were similar to those from other investigations, further demonstrating the replication of the WISC-IV factor structure across cultures and the importance of focusing primary interpretation on the FSIQ.

Incremental validity of WISC-IV(UK) factor index scores with a referred Irish sample: predicting performance on the WIAT-II(UK.).

BACKGROUND: Subtest and factor scores have typically provided little incremental predictive validity beyond the omnibus IQ score. AIMS: This study examined the incremental validity of Wechsler Intelligence Scale for Children - Fourth UK Edition (WISC-IV(UK) ; Wechsler, 2004a, Wechsler Intelligence Scale for Children - Fourth UK Edition, Harcourt Assessment, London, UK) and factor index scores in predicting academic achievement on the Wechsler Individual Achievement Test - Second UK Edition (WIAT-II(UK) ; Wechsler, 2005a, Wechsler Individual Achievement Test-Second UK Edition, Pearson, London, UK), beyond that predicted by the WISC-IV(UK) FSIQ. SAMPLE: The sample included 1,014 Irish children (ages 6-0 to 16-9) who were referred for evaluation of learning difficulties. METHOD: Hierarchical multiple regression analyses were used with the WISC-IV(UK) FSIQ (Block 1) and factor index scores (Block 2) as predictors and WIAT-II(UK) subtest and composite scores as dependent variables. RESULTS: The WISC-IV(UK) FSIQ accounted for statistically significant and generally large portions of WIAT-II(UK) subtest and composite score variance. WISC-IV(UK) factor index scores combined to provide statistically significant increments in prediction of most WIAT-II(UK) subtest and composite scores over and above the FSIQ; however, the effect sizes were mostly small as previously observed (i.e., Canivez, 2013a, Psychol. Assess., 25, 484; Glutting et al., 2006, J. Spec. Educ., 40, 103; Nelson et al., 2013, Psychol. Assess., 25, 618). Individually, the WISC-IV(UK) factor index scores provided small unique contributions to predicting WIAT-II(UK) scores. CONCLUSION: This, in combination with studies of apportioned variance from bifactor confirmatory factor analysis (Watkins et al., 2013, Int. J. Sch. Educ. Psychol., 1, 102), indicated that the WISC-IV(UK) FSIQ should retain the greatest weight in WISC-IV(UK) interpretation.

The use of enhanced recovery after surgery (ERAS) principles in Scottish orthopaedic units--an implementation and follow-up at 1 year, 2010-2011: a report from the Musculoskeletal Audit, Scotland.

OBJECTIVE: To establish whether a nationally guided programme can lead to more widespread implementation of enhanced recovery after surgery (ERAS), a well-established optimised care pathway for lower limb arthroplasty. DESIGN: In 2010, National Services Scotland's Musculoskeletal Audit was asked to perform a 'snapshot' audit of the current peri-operative management of patients undergoing total hip and knee arthroplasty in all 22 Scottish orthopaedic units with an identical follow-up audit in 2011 after input and support from the national steering group. POPULATION: Audit 1 and audit 2 involved 1,345 and 1,278 patients, respectively. RESULTS: The number of Scottish units that developed an ERAS programme increased from 8 (36 %) to 15 (68 %). Units that included more ERAS patients had earlier mobilisation rates (146/474, 36 % ERAS patients mobilised same day vs. 34/873, 4 % non-ERAS; n = 22 units, r = 0.55, p = 0.008) and shorter post-operative length of stay (median 4 days vs. ERAS, 5 days non-ERAS, n = 22 units, r = -0.64, p = 0.001). ERAS knee arthroplasty patients had lower blood transfusion rates (5/205, 2 % vs. 51/399, 13 %, n = 22 units, r = -0.62, p = 0.002). Units that restricted the use of IV fluids post-operatively had higher early mobilisation rates (n = 22 units, r = 0.48, p = 0.03) and shorter post-operative length of stay (n = 22 units, r = -0.56, p = 0.007). Reduced use of patient-controlled analgesia was also associated with earlier mobilisation (n = 22 units, r = 0.49, p = 0.02) and shorter length of stay (n = 22 units, r = -0.39, p = 0.07). Urinary catheterisation rates also dropped from 468/1,345 (35 %) in 2010 to 337/1,278 (26 %) in 2011 (n = 22 units, z = 2.19, p = 0.03). CONCLUSION: A clinically guided and nationally supported process has proven highly successful in achieving a further uptake of enhanced recovery principles after lower limb arthroplasty in Scotland, which has resulted in clinical benefits to patients and reduced length of hospital stay.

Glassware washers: cleaning glassware and implements used in compounding, part 2.

Compounding with glassware and utensils that are contaminated with drug residues or pyrogens is a recipe for disaster. Using a powerful glassware washer, which can ensure that compounding implements are clean and free of contaminants, may be a worthwhile investment for compounding pharmacies in which the volume of preparations justifies the washer's cost. A glassware washer provides cleaning superior to that of residential or commercial dishwashers and offers other advantages that range from reproducible cycle parameters to programs that can be configured for specific cleaning needs to the ability to provide a purified-water rinse. In this article, a compounder's decision to purchase a glassware washer--and the results of that decision--are described, and factors that are critical in the selection of a washer for use in a compounding laboratory are listed. Specifications for glassware washers are compared in a Table, and an easy method of determining the time and cost of automatic washing versus handwashing is presented.

Randomized controlled trial of adherence with single or combination inhaled corticosteroid/long-acting beta-agonist inhaler therapy in asthma.

BACKGROUND: The inhaled corticosteroid (ICS)/long-acting beta-agonist (LABA) combination inhaler has the potential to improve adherence with ICS therapy in asthma. OBJECTIVE: To determine whether ICS/LABA combination inhaler therapy improves adherence compared with separate inhaler use. METHODS: In a 24-week randomized controlled parallel group study, 111 subjects were prescribed 125 microg fluticasone dipropionate (FP) and 25 microg salmeterol, 2 actuations twice daily through either a combination inhaler or separate inhalers concurrently. Medication use was recorded by covert electronic monitors. The primary outcome variable was adherence during the final 6-week period, defined as the number of doses taken as a percentage of those prescribed. RESULTS: Complete adherence data from the final 6-week period were available for 49 and 54 subjects in the separate and combination groups, respectively. The mean (SD) adherence was 73.7% (36.0) for FP, 76.7% (30.5) for salmeterol, and 82.4% (24.5) for FP/salmeterol. There were no significant differences in adherence between FP/salmeterol and FP (-8.7%; 95% CI, -10.6 to 3.3) and salmeterol (-5.6%; 95% CI, -16.4 to 5.1). There was no significant difference in overuse among the FP, salmeterol, or FP/salmeterol groups. In 2 (4%) of 49 subjects, salmeterol was effectively taken as monotherapy during a 6-week period. CONCLUSION: In the setting of a randomized controlled trial, use of a combination ICS/LABA inhaler does not markedly increase adherence above that observed with separate inhaler use. LABA monotherapy was observed in a small proportion of patients prescribed ICS and LABA therapy via separate inhalers.

An audit of the effect of oxygen prescription charts on clinical practice.

PROBLEM: The need to improve the prescription, administration and monitoring of oxygen therapy. DESIGN: An interventional, prospective audit. BACKGROUND AND SETTING: Wellington Hospital, a teaching and tertiary referral hospital in New Zealand in 2007 and 2008. KEY MEASURES FOR IMPROVEMENT: Demonstration of adequate oxygen prescribing, administration and monitoring of oxygen therapy. STRATEGIES FOR IMPROVEMENT: The introduction of a new drug chart with a specific oxygen prescription section. Targeted educational lectures primarily to medical staff. EFFECTS OF CHANGE: 610 and 566 patients were reviewed in the first and second audits. After introduction of the new oxygen prescription section on the drug chart the proportion of patients whose oxygen therapy was prescribed increased from 15/85 (17.6%) to 39/98 (39.8%), relative risk 2.3 (95% CI 1.3 to 3.9). The proportion with adequate oxygen prescription, with documentation of device, flow rate or inspired oxygen concentration, and the target oxygen saturation increased from 5/85 (5.9%) to 36/98 (36.7%), relative risk 6.2 (95% CI 2.5 to 15.0). Introduction of the new charts was not associated with changes in clinical practice in terms of assessment of oxygen saturations on room air and commencement if < or = 92%, or the titration of oxygen therapy in response to oxygen saturations < or = 92%. LESSONS LEARNT: An oxygen prescription section on hospital drug charts improved the prescription of oxygen but did not improve clinical practice. Additional strategies are required to improve the administration of oxygen therapy in hospitals.

Dose-response relationship of inhaled corticosteroids and cataracts: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: The risk of cataracts associated with the long-term use of inhaled corticosteroids (ICS) is poorly recognized, yet may be of major public health importance. The aim of this study was to determine the dose-response relationship of ICS use and risk of cataracts in adults. METHODS: A systematic review and meta-analysis was performed of case-control studies of cataracts and ICS use, which included at least two doses of ICS and in which the number of cases and controls using each dose of ICS was reported. The primary outcome variable was risk of cataracts. RESULTS: Four case-control studies were identified, with a total of 46 638 cases and 146 378 controls. There was a significant relationship between the risk of cataracts and ICS dose, with a random effects pooled odds ratio for risk of cataracts per 1000 microg increase in daily beclomethasone dipropionate dose of 1.25 (95% CI: 1.14-1.37). CONCLUSIONS: The risk of cataracts was increased by approximately 25% for each 1000 microg per day increase in the dose of beclomethasone dipropionate or equivalent. These findings reinforce the importance of prescribing within the therapeutic dose-response range for ICS in asthma and the need to determine the dose-response relationship for the efficacy of ICS in COPD. Screening for the presence of cataracts could usefully be undertaken in older subjects with asthma and COPD, particularly current or ex-smokers.

Information loss in 2 bleb grading systems.

PURPOSE: To assess the effectiveness of transferring descriptive information from bleb photographs to 2 recently described bleb grading systems: the Moorfields Bleb Grading System (MBGS) and the Indiana Bleb Appearance Grading Scale (IBAGS). METHODS: Two experienced observers graded 51 clinical bleb photographs with a wide range of appearances using both the MBGS and IBAGS bleb grading systems in random order. Grading scores from the 2 observers were averaged, and these numbers used by a third investigator, who did not view the original photographs, to generate 102 sketched representations of the blebs. The sketches were labeled randomly, and 1 month later presented individually in random order, to mask which grading system was used as source data for each drawing. MAIN OUTCOME MEASURES: The original graders then used an arbitrary 1-5 scale to rate congruity between sketches and photographs for vascularity and morphology features, and overall agreement of the bleb sketches. RESULTS: For both the IBAGS and MBGS, interobserver agreement between the Congruity Scores (CS) of the 2 masked graders was excellent, ranging between 92% and 98% for each parameter. Overall CS results were 3.2 (good-very good) for IBAGS and 4.1 (very good-excellent) for MBGS. Vascularity CS scores from IBAGS were 3.0 (good) and those from morphology agreement averaged 3.5 (good-very good). For the MBGS, the respective results were 3.9 (good-very good) and 4.1 (very good-excellent), respectively. Photographic quality (P=0.012) and presence of a limbus-based conjunctival flap scar (P=0.012) had an influence on CS scores from IBAGS but not from MBGS. CONCLUSIONS: Both the IBAGS and MBGS produced acceptable agreement ratings between the sketches derived from grading system data and the original bleb photographs. These grading systems seem to adequately represent the blebs that are being encoded, without significant information loss from the simplification and translation process. The MBGS tended to have higher CS, and may be less influenced by photograph quality and bleb type, suggesting that bleb photographs may be best encoded for statistical analysis in clinical studies using this system.