Retrospective Review of Directional Atherectomy and Drug-Coated Balloon Use in a PAD Safety-Net Population.

BACKGROUND: Peripheral artery disease (PAD) is associated with high morbidity and mortality, particularly once patients develop critical limb threatening ischemia (CLTI). Minorities and vulnerable populations often present with CLTI and experience worse outcomes. The use of directional atherectomy (DA) and drug-coated balloon (DCB) during lower-extremity revascularization (LER) has not been previously described in a safety-net population. OBJECTIVE: To review demographic and clinical characteristics, and short- intermediate term outcomes of patients presenting to a safety-net hospital with PAD treated with DA and DCB during LER. METHODS: In this retrospective, observational cohort study, chart review was performed of all patients who underwent DA and DCB during LER for PAD from April 2016 to January 2020 in a safety-net hospital. RESULTS: The analysis included 58 patients, with 41% female, 24% Black/African American, and 31% Hispanic. From this group, 17% spoke a non-English primary language and 10% reported current or previous housing insecurity. Most (65%) presented with CLTI and had undergone a previous index leg LER (58%). The combination of DA and DCB was efficacious, resulting in low rates of bail-out stenting (16%) and target-vessel revascularization (26%) at 2 years. Low complication rates (tibial embolism in 12% and vessel perforation in 2% of cases) were also observed. Most patients (67%) with Rutherford category 5 experienced wound healing by 2 years. CONCLUSION: In this safety-net population, the majority presented with CLTI and a previous LER of the index leg. The combination of DA and DCB resulted in low complication rates, and good short-intermediate outcomes in this frequently undertreated population.

Investigating effective testing strategies for the control of Johne's disease in western Canadian cow-calf herds using an agent-based simulation model.

Johne's disease is an insidious infectious disease of ruminants caused by Mycobacterium avium subspecies paratuberculosis (MAP). Johne's disease can have important implications for animal welfare and risks causing economic losses in affected herds due to reduced productivity, premature culling and replacement, and veterinary costs. Despite the limited accuracy of diagnostic tools, testing and culling is the primary option for controlling Johne's disease in beef herds. However, evidence to inform specific test and cull strategies is lacking. In this study, a stochastic, continuous-time agent-based model was developed to investigate Johne's disease and potential control options in a typical western Canadian cow-calf herd. The objective of this study was to compare different testing and culling scenarios that included varying the testing method and frequency as well as the number and risk profile of animals targeted for testing using the model. The relative effectiveness of each testing scenario was determined by the simulated prevalence of cattle shedding MAP after a 10-year testing period. A second objective was to compare the direct testing costs of each scenario to identify least-cost options that are the most effective at reducing within-herd disease prevalence. Whole herd testing with individual PCR at frequencies of 6 or 12 months were the most effective options for reducing disease prevalence. Scenarios that were also effective at reducing prevalence but with the lowest total testing costs included testing the whole herd with individual PCR every 24 months and testing the whole herd with pooled PCR every 12 months. The most effective method with the lowest annual testing cost per unit of prevalence reduction was individual PCR on the whole herd every 24 months. Individual PCR testing only cows that had not already been tested 4 times also ranked well when considering both final estimated prevalence at 10 years and cost per unit of gain. A more in-depth economic analysis is needed to compare the cost of testing to the cost of disease, taking into account costs of culling, replacements and impacts on calf crops, and to determine if testing is an economically attractive option for commercial cow-calf operations.

Seroprevalence of Mycobacterium avium spp. paratuberculosis in cow-calf herds located in the prairie provinces of Canada.

Objective: To determine the prevalence of Mycobacterium avium spp. paratuberculosis (MAP) in cow-calf herds located in the prairie provinces of Alberta, Saskatchewan, and Manitoba using a serum ELISA test. Animals: Study herds were recruited from the Western Canadian Cow-calf Surveillance Network (WC3SN) designed to monitor factors related to the health and productivity of cow-calf herds. Overall, 1791 cows from 92 herds were included in the study. Procedure: Blood samples were collected from 20 cows per herd in a systematic random fashion by private veterinarians in the fall of 2014. A serum ELISA (IDEXX, Westbrook, Maine, USA) test was used for the detection of MAP antibodies in the blood samples. Results: The cow level seroprevalence across all 3 provinces was 1.5%. Alberta had the lowest cow seroprevalence (1.3%) followed by Saskatchewan (1.7%), and Manitoba (2.1%). Herd level data showed that 24% of herds had at least 1 positive animal and 5% had at least 2 positive animals. Seroprevalence estimates varied between geographical regions within each province and with herd size. Conclusions: The apparent prevalence of MAP in prairie cow-calf herds remains low and similar to past estimates for the region. However, controlling the spread of Johne's disease in the western Canadian cow-calf herd should be considered an important discussion point in the beef industry. Clinical relevance: Ongoing surveillance of Johne's disease in western Canadian beef herds is necessary for mitigating disease spread before it becomes a disease of major concern within the industry.

Séroprévalence de Mycobacterium avium spp. paratuberculosis dans les troupeaux de vaches-veaux situés dans les provinces des Prairies du Canada. Objectif: Pour déterminer la prévalence de Mycobacterium avium spp. paratuberculosis (MAP) dans des troupeaux de vachesveaux situés dans les provinces des Prairies de l'Alberta, de la Saskatchewan et du Manitoba à l'aide d'un test ELISA sérique. Animaux: Les troupeaux à l'étude ont été recrutés à partir du Réseau de surveillance des vaches-veaux de l'Ouest canadien (WC3SN) conçu pour surveiller les facteurs liés à la santé et à la productivité des troupeaux de vaches-veaux. Au total, 1791 vaches de 92 troupeaux ont été incluses dans l'étude. Procédure: Des échantillons de sang ont été prélevés de 20 vaches par troupeau de façon aléatoire systématique par des vétérinaires en pratique privée à l'automne 2014. Un test ELISA sérique (IDEXX, Westbrook, Maine, États-Unis) a été utilisé pour la détection des anticorps MAP dans les échantillons de sang. Résultats: La séroprévalence chez les vaches dans les trois provinces était de 1,5 %. L'Alberta avait la plus faible séroprévalence chez les vaches (1,3 %), suivie de la Saskatchewan (1,7 %) et du Manitoba (2,1 %). Les données au niveau du troupeau ont montré que 24 % des troupeaux avaient au moins un animal positif et 5 % avaient au moins deux animaux positifs. Les estimations de la séroprévalence variaient entre les régions géographiques de chaque province et selon la taille du troupeau. Conclusions: La prévalence apparente de la MAP dans les troupeaux de vaches-veaux des Prairies demeure faible et semblable aux estimations antérieures pour la région. Cependant, la maitrise de la propagation de la maladie de Johne dans le troupeau vache-veau de l'Ouest canadien devrait être considérée comme un point de discussion important dans l'industrie bovine. Pertinence clinique: La surveillance continue de la maladie de Johne dans les troupeaux de bovins de boucherie de l'Ouest canadien est nécessaire pour atténuer la propagation de la maladie avant qu'elle ne devienne une maladie préoccupante au sein de l'industrie.(Traduit par Dr Serge Messier).

Estimating the sensitivity and specificity of serum ELISA and pooled and individual fecal PCR for detecting Mycobacterium avium subspecies paratuberculosis in Canadian cow-calf herds using Bayesian latent class models.

While Johne's disease (JD) is less common in beef than in dairy herds, consolidation is increasing transmission risk. Estimates of Mycobacterium avium spp. paratuberculosis (MAP) prevalence and test performance in cow-calf herds are needed to inform control programs. Objectives of this study included describing the prevalence of MAP in Canadian cow-calf herds and comparing the relative performance of a serum ELISA, pooled fecal PCR and individual fecal PCR using Bayesian latent class models, and to investigate factors associated with positive MAP tests. Blood and fecal samples (n = 3,171) were collected from 159 Canadian cow-calf herds. All samples were analyzed using serum ELISA and fecal PCR (pools of five samples) and a subset of 913 fecal samples were also tested with individual PCR. Based on latent class analysis, MAP prevalence was higher in eastern compared to western Canada for both animals {East, 3% [95% Credible Interval (CrI) 1-7%]; West, 1% [95% CrI 0.2-2%]} and herds [East, 15% (95% CrI 2-35%); West, 10% (95% CrI 1-26%), based on one or more positive results]. Sensitivity (Se) and specificity (Sp) for animal level individual PCR were 96% (95% CrI 80-100%) and 98% (95% CrI 96-100%), respectively followed by pooled PCR [Se = 54% (95% CrI 36-72%), Sp > 99.9% (95% CrI 99.8-100%)] and ELISA [Se = 36% (95% CrI 22-52%), Sp = 98% (95% CrI 96-99%)]. Based on 20 samples per herd, the herd level Se of ELISA was 79% (95% CrI 47-100%) (at least one positive sample) compared to 43% (95% CrI 14-94%) for pooled PCR. Herd-level Sp was 99% (95% CrI 96-100%) for pooled PCR and 90% (95% CrI 83-100%) for ELISA. Cows from herds with dairy cattle on farm and cows with symptoms of JD in the past 3 years were more likely to be MAP positive. Herds that had animals with JD symptoms in the previous 3 years and those with more breeding females were most likely to test positive for MAP. While serum ELISA can be effective for herd screening, PCR performed better for animal testing. Pooled PCR testing could be a less costly option; however, determining the most cost-effective approach will require further economic analysis.

Implementation of a diabetes clinic-in-a-clinic project in a family practice setting: using the plan, do, study, act model.

OBJECTIVES: The American Association of Diabetic Educators suggests that educating patients about their diabetes management facilitates problem solving and coping skills. This paper will describe a clinic-in-a-clinic model of care delivery founded on the principles of the Chronic Care Model and focused towards the outcomes proposed by the American Association of Diabetic Educators. The reader will be introduced to the use of the 'plan, do, study, act' process used to develop this model in a clinical setting. BACKGROUND: Self-management support, a key component of the Chronic Care Model, focuses on providing patients with the skills to make healthcare decisions. Self-management encourages patient to be responsible for his/her own health care. Because diabetes outcomes and complication prevalence are related to the degree of self involvement in illness care, self-management support is an important component of disease management. DESIGN: Plan, do, study, act model for program development. METHODS: The 'plan, do, study, act' cycles outlined the steps needed to implement the clinic-in-a-clinic program with success related to coordination of all components and continual assessment and revision. Each cycle was initiated in a sequential order allowing for evaluation and goal adjustment before the next cycle was implemented. CONCLUSIONS: The majority of patients seen were middle-aged, obese, females with HbA1cs greatly above the recommended 7.0. Patients selected a variety of topics related to diabetes management for their clinical session. Participation rates were consistent with regular clinic visit attendance. Barriers to success of the program were related to both structure and process. RELEVANCE TO CLINICAL PRACTICE: The clinic-in-a-clinic design moves disease management from individual practice into a property of the health systems and places importance on the collaboration of patient, provider and delivery system in reducing the consequences of chronic illness. Use of the 'plan, do, study, act' cycle model offers a method for changing the process of care delivery in a structured, sequential approach.