Correlation of SARS-CoV-2 in Wastewater and Individual Testing Results in a Jail, Atlanta, Georgia, USA.

Institution-level wastewater-based surveillance was implemented during the COVID-19 pandemic, including in carceral facilities. We examined the relationship between COVID-19 diagnostic test results of residents in a jail in Atlanta, Georgia, USA (average population ≈2,700), and quantitative reverse transcription PCR signal for SARS-CoV-2 in weekly wastewater samples collected during October 2021‒May 2022. The jail offered residents rapid antigen testing at entry and periodic mass screenings by reverse transcription PCR of self-collected nasal swab specimens. We aggregated individual test data, calculated the Spearman correlation coefficient, and performed logistic regression to examine the relationship between strength of SARS-CoV-2 PCR signal (cycle threshold value) in wastewater and percentage of jail population that tested positive for COVID-19. Of 13,745 nasal specimens collected, 3.9% were COVID-positive (range 0%-29.5% per week). We observed a strong inverse correlation between diagnostic test positivity and cycle threshold value (r = -0.67; p<0.01). Wastewater-based surveillance represents an effective strategy for jailwide surveillance of COVID-19.

Evaluation of the Cost-Effectiveness of Evidence-Based Interventions to Increase Female Breast and Cervical Cancer Screens: A Systematic Review.

PURPOSE: To systematically review published cost-effectiveness analyses of Evidence-Based Interventions (EBIs) recommended by the United States Community Preventive Services Task Force (CPSTF) to increase breast and cervical cancer screening. METHODS: We searched PubMed and Embase for prospective cost-effectiveness evaluations of EBIs for breast and cervical cancer screening since 1999. We reviewed studies according to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) and compared the incremental cost-effectiveness ratio (ICERs), defined as cost per additional woman screened, adjusted to 2021 USD, within and across EBIs by cancer type. RESULTS: We identified eleven studies meeting our review criteria: nine were breast cancer-focused, one breast and cervical cancer combined, and one cervical only, which together reported twenty-four cost-effectiveness assessments of outreach programs spanning eight EBIs. One-on-one education programs were the most common EBI evaluated. The average ICER across breast cancer studies was USD 545 (standard deviation [SD] = USD 729.3), while that for cervical cancer studies was USD 197 (SD = 186.6. Provider reminder/recall systems for women already linked to formal care were the most cost-effective, with an average ICERs of USD 41.3 and USD 10.6 for breast and cervical cancer, respectively. CONCLUSIONS: Variability in ICERs across and within EBIs reflect the population studied, the specific EBI, and study settings, and was relatively high. ICER estimate uncertainty and the potential for program replicability in other settings and with other populations were not addressed. Given these limitations, using existing cost-effectiveness estimates to inform program funding allocations is not warranted at this time. Additional research is needed on outreach programs for cervical cancer and those which serve minority populations for either of the female cancer screens.

CLINICAL AND SUBCLINICAL CYTAUXZOON FELIS INFECTIONS IN DOMESTIC CATS FROM A RECENTLY IDENTIFIED ENDEMIC REGION.

Cytauxzoon felis is a tick-transmitted intraerythrocytic apicomplexan infecting felids in the southeastern and midwestern United States. Bobcats (Lynx rufus) are the natural wildlife reservoir of C. felis, where in enzootic areas prevalence can reach 100%. Domestic cats can be subclinically infected with C. felis or can develop cytauxzoonosis. Two studies have documented the presence of C. felis in domestic cats in Illinois; these studies have shown a limited number of cases submitted to specialty labs. During 2014-2018, we obtained blood samples collected by veterinary staff from 514 cats that were apparently healthy and 74 cats that were suspected of cytauxzoonosis. These samples were screened using a sensitive, nested PCR to detect the presence of C. felis DNA. We herein document frequent occurrences of cytauxzoonosis (8-15 cases/year from 4 veterinary clinics) and 12.5% prevalence of subclinical infections in southern Illinois, a locality showing a sharp increase in cases of cytauxzoonosis. Our results suggest a high risk of cytauxzoonosis in southern Illinois, despite only recently being recognized in the area. We found no specific risk factors for cytauxzoonosis or subclinical infections in this location. In addition, cases of cytauxzoonosis occur every month of the year (with the highest frequency in summer) and therefore tick prevention should be used in domestic cats in enzootic regions throughout the year.

Prophylactic use of a lidocaine constant rate infusion versus saline in dogs undergoing balloon valvuloplasty for management of pulmonic stenosis: A randomized control trial.

OBJECTIVE: To evaluate the effect of a prophylactic lidocaine constant rate infusion (CRI) on the incidence and malignancy of catheter-induced ventricular ectopic complexes (VECs) during balloon valvuloplasty for management of pulmonic stenosis in dogs. STUDY DESIGN: Single-centre, prospective, randomized study. ANIMALS: Client-owned dogs (n = 70) with pulmonic stenosis. METHODS: Dogs were randomly assigned to one of two anaesthetic protocols: administration of lidocaine 2 mg kg-1 bolus followed by a CRI (50 µg kg-1 minute-1; group LD) or a saline placebo (group SL) during balloon valvuloplasty. All dogs were premedicated with methadone (0.3 mg kg-1) intramuscularly and a digital three-lead Holter monitor was applied. Anaesthetic co-induction was performed with administration of alfaxalone (2 mg kg-1) and diazepam (0.4 mg kg-1), and anaesthesia was maintained with isoflurane vaporised in 100% oxygen. CRIs were started on positioning of the dog in theatre and discontinued as the last vascular catheter was removed from the heart. All dogs recovered well and were discharged 24 hours postoperatively. Blinded Holter analysis was performed by an external veterinary cardiologist using commercially available dedicated analysis software; p < 0.05. RESULTS: Of the 70 dogs enrolled in the study, 61 were included in the final analysis: 31 in group LD and 30 in group SL. There was no significant difference between sinus beats (p = 0.227) or VECs (p = 0.519) between groups. In group LD, 19/31 (61.3%) dogs had a maximum ventricular rate ≥250 units and 20/30 (66.7%) dogs in group SL (p = 0.791). CONCLUSION AND CLINICAL RELEVANCE: In this study, the use of a prophylactic lidocaine bolus followed by CRI in dogs undergoing balloon valvuloplasty for management of pulmonic stenosis did not significantly decrease the incidence nor the malignancy of VECs during right heart catheterization compared with a saline CRI.

Cost of peer mystery shopping to increase cultural competency in community clinics offering HIV/STI testing to young men who have sex with men: results from the get connected trial.

INTRODUCTION: Cultural competency has been identified as a barrier to lesbian, gay, bisexual and transgender (LGBT) populations seeking care. Mystery shopping has been widely employed in the formal health care sector as a quality improvement (QI) tool to address specific client needs. The approach has had limited use in community-based organizations due in part to lack of knowledge and resource requirement concerns. Several mystery shopping initiatives are now being implemented which focus on the LGBT population with the goal of reducing barriers to accessing care. One subset targets men who have sex with men (MSM) to increase uptake of human immunodeficiency virus (HIV) testing. No study investigates the costs of these initiatives. Get Connected was a randomized control trial with the objective of increasing uptake of HIV-prevention services among young men who have sex with men (YMSM) through use of a resource-locator application (App). The initial phase of the trial employed peer-led mystery shopping to identify culturally competent HIV testing sites for inclusion in the App. The second phase of the trial randomized YMSM to test the efficacy of the App. Our objective was to determine the resource inputs and costs of peer-led mystery shopping to identify clinics for inclusion in the App as costs would be critical in informing possible adoption by organizations and sustainability of this model. METHODS: Through consultation with study staff, we created a resource inventory for undertaking the community-based, peer-led mystery shopping program. We used activity-based costing to price each of the inputs. We classified inputs as start-up and those for on-going implementation. We calculated costs for each category, total costs and cost per mystery shopper visit for the four-month trial and annually to reflect standard budgeting periods for data collected from September of 2019 through September of 2020. RESULTS: Recruitment and training of peer mystery shoppers were the most expensive tasks. Average start-up costs were $10,001 (SD $39.8). Four-month average implementation costs per visit were $228 (SD $1.97). Average annual implementation costs per visit were 33% lower at $151 (SD $5.60). CONCLUSIONS: Peer-led, mystery shopping of HIV-testing sites is feasible, and is likely affordable for medium to large public health departments.

Opinions of former jail residents about self-collection of SARS-CoV-2 specimens, paired with wastewater surveillance: A qualitative study rapidly examining acceptability of COVID-19 mitigation measures.

In year one of the COVID-19 epidemic, the incidence of infection for US carceral populations was 5.5-fold higher than that in the community. Prior to the rapid roll out of a comprehensive jail surveillance program of Wastewater-Based Surveillance (WBS) and individual testing for SARS-CoV-2, we sought the perspectives of formerly incarcerated individuals regarding mitigation strategies against COVID-19 to inform acceptability of the new program. In focus groups, participants discussed barriers to their receiving COVID-19 testing and vaccination. We introduced WBS and individual nasal self-testing, then queried if wastewater testing to improve surveillance of emerging outbreaks before case numbers surged, and specimen self-collection, would be valued. The participants' input gives insight into ways to improve the delivery of COVID-19 interventions. Hearing the voices of those with lived experiences of incarceration is critical to understanding their views on infection control strategies and supports including justice-involved individuals in decision-making processes regarding jail-based interventions.

Identification of actionable targets for breast cancer intervention using a diversity outbred mouse model.

HER2-targeted therapy has improved breast cancer survival, but treatment resistance and disease prevention remain major challenges. Genes that enable HER2/Neu oncogenesis are the next intervention targets. A bioinformatics discovery platform of HER2/Neu-expressing Diversity Outbred (DO) F1 Mice was established to identify cancer-enabling genes. Quantitative Trait Loci (QTL) associated with onset ages and growth rates of spontaneous mammary tumors were sought. Twenty-six genes in 3 QTL contain sequence variations unique to the genetic backgrounds that are linked to aggressive tumors and 21 genes are associated with human breast cancer survival. Concurrent identification of TSC22D3, a transcription factor, and its target gene LILRB4, a myeloid cell checkpoint receptor, suggests an immune axis for regulation, or intervention, of disease. We also investigated TIEG1 gene that impedes tumor immunity but suppresses tumor growth. Although not an actionable target, TIEG1 study revealed genetic regulation of tumor progression, forming the basis of the genetics-based discovery platform.

Cost-effectiveness of a multicomponent quality improvement care model for diabetes in South Asia: The CARRS randomized clinical trial.

OBJECTIVES: To assess the cost-effectiveness of a multicomponent strategy versus usual care in people with type 2 diabetes in South Asia. DESIGN: Economic evaluation from healthcare system and societal perspectives. SETTING: Ten diverse urban clinics in India and Pakistan. PARTICIPANTS: 1146 people with type 2 diabetes (575 in the intervention group and 571 in the usual care group) with mean age of 54.2 years, median diabetes duration: 7 years and mean HbA1c: 9.9% (85 mmol/mol) at baseline. INTERVENTION: Multicomponent strategy comprising decision-supported electronic health records and non-physician care coordinator. Control group received usual care. OUTCOME MEASURES: Incremental cost-effectiveness ratios (ICERs) per unit achievement in multiple risk factor control (HbA1c <7% (53 mmol/mol) and SBP <130/80 mmHg or LDLc <2.58 mmol/L (100 mg/dL)), ICERs per unit reduction in HbA1c, 5-mmHg unit reductions in systolic BP, 10-unit reductions in LDLc (mg/dl) (considered as clinically relevant) and ICER per quality-adjusted life years (QALYs) gained. ICERs were reported in 2020 purchasing power parity-adjusted international dollars (INT$). The probability of ICERs being cost-effective was considered depending on the willingness to pay (WTP) values as a share of GDP per capita for India (Int$ 7041.4) and Pakistan (Int$ 4847.6). RESULTS: Compared to usual care, the annual incremental costs per person for intervention group were Int$ 1061.9 from a health system perspective and Int$ 1093.6 from a societal perspective. The ICER was Int$ 10,874.6 per increase in multiple risk factor control, $2588.1 per one percentage point reduction in the HbA1c, and $1744.6 per 5 unit reduction in SBP (mmHg), and $1271 per 10 unit reduction in LDLc (mg/dl). The ICER per QALY gained was $33,399.6 from a societal perspective. CONCLUSIONS: In a trial setting in South Asia, a multicomponent strategy for diabetes care resulted in better multiple risk factor control at higher costs and may be cost-effective depending on the willingness to pay threshold with substantial uncertainty around cost-effectiveness for QALYs gained in the short term (2.5 years). Future research needs to confirm the long-term cost-effectiveness of intensive multifactorial intervention for diabetes care in diverse healthcare settings in LMICs.

The cost-effectiveness of targeted screening for congenital cytomegalovirus in newborns compared to clinical diagnosis in the US.

OBJECTIVE: Congenital cytomegalovirus (cCMV) is the leading environmental cause of hearing loss (HL) among children, affecting four in one thousand newborns. cCMV testing in the US is currently based on clinical diagnosis which does not consistently identify cCMV cases and precludes early intervention to prevent and reduce the severity of HL. We estimated the cost-effectiveness of targeted newborn screening and cCMV testing among newborns compared to clinical diagnosis. METHODS: We use a decision-analytic model to estimate the costs of preventing HL progression, of additional cases of severe HL, of identifying a case of HL one year earlier, and of identifying an additional case of cCMV, through targeted screening and cCMV testing for infants failing two newborn hearing screens with follow-up to age five. We also estimate the costs of nationwide implementation of a newborn screening and testing program. Model pathways were based on best practices for screening, testing, and treatment. Probabilities were drawn from the published literature; costs were estimated based on Medicare reimbursement rates. Probabilistic and scenario analyses were conducted to determine the robustness of results. RESULTS: Targeted testing and cCMV screening, compared to standard of care, cost an additional $2.96 (±2.26) per infant screened and identified 0.00038 (±0.00022) cases of HL, 3.8 in 10000 children, at a cost of $8197 (±4217) per case of HL identified. Implementing targeted screening for all children in the US was estimated to cost $193,229. CONCLUSIONS: Although cases numbers are small, our model shows that targeted newborn screening and cCMV testing reduced cases of HL progression. Adoption of newborn targeted screening as standard of care should be considered given it may prevent disability at very low cost.

Coping with COVID in corrections: a qualitative study among the recently incarcerated on infection control and the acceptability of wastewater-based surveillance.

BACKGROUND: Correctional settings are hotspots for SARS-CoV-2 transmission. Social and biological risk factors contribute to higher rates of COVID-19 morbidity and mortality among justice-involved individuals. Rapidly identifying new cases in congregate settings is essential to promote proper isolation and quarantine. We sought perspectives of individuals incarcerated during COVID-19 on how to improve carceral infection control and their perspectives on acceptability of wastewater-based surveillance (WBS) accompanying individual testing. METHODS: We conducted semi-structured interviews with 20 adults who self-reported being incarcerated throughout the United States between March 2020 and May 2021. We asked participants about facility enforcement of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines, and acceptability of integrating WBS into SARS-CoV-2 monitoring strategies at their most recent facility. We used descriptive statistics to characterize the study sample and report on acceptability of WBS. We analyzed qualitative data thematically using an iterative process. RESULTS: Participants were predominantly Black or multiple races (50%) and men (75%); 46 years old on average. Most received a mask during their most recent incarceration (90%), although only 40% received counseling on proper mask wearing. A quarter of participants were tested for SARS-CoV-2 at intake. Most (70%) believed they were exposed to the virus while incarcerated. Reoccurring themes included (1) Correctional facility environment leading to a sense of insecurity, (2) Perceptions that punitive conditions in correctional settings were exacerbated by the pandemic; (3) Importance of peers as a source of information about mitigation measures; (4) Perceptions that the safety of correctional environments differed from that of the community during the pandemic; and (5) WBS as a logical strategy, with most (68%) believing WBS would work in the last correctional facility they were in, and 79% preferred monitoring SARS-CoV-2 levels through WBS rather than relying on just individual testing. CONCLUSION: Participants supported routine WBS to monitor for SARS-CoV-2. Integrating WBS into existing surveillance strategies at correctional facilities may minimize the impact of future COVID-19 outbreaks while conserving already constrained resources. To enhance the perception and reality that correctional systems are maximizing mitigation, future measures might include focusing on closer adherence to CDC recommendations and clarity about disease pathogenesis with residents.

Carboxyl-terminal modulator protein (CTMP) deficiency mitigates denervation-induced skeletal muscle atrophy.

Denervated skeletal muscles show decreased Akt activity and phosphorylation, resulting in atrophy. Akt inhibits downstream transcription of atrophy-associated ubiquitin ligases like muscle ring-finger protein 1 (MuRF-1). In addition, reduced Akt signaling contributes to aberrant protein synthesis in muscles. In ALS mice, we recently found that carboxyl-terminator modulator protein (CTMP) expression is increased and correlated with reduced Akt signaling in atrophic skeletal muscle. CTMP has also been implicated in promoting muscle degeneration and catabolism in an in vitro muscle atrophy model. The present study examined whether sciatic nerve injury (SNI) stimulated CTMP expression in denervated skeletal muscle during muscle atrophy. We hypothesized that CTMP deficiency would reduce neurogenic atrophy and reverse Akt signaling downregulation. Compared to the unaffected contralateral muscle, wild-type (WT) gastrocnemius muscle had a significant increase in CTMP (p < 0.05). Furthermore, denervated CTMP knockout (CTMP-KO) gastrocnemius weighed more than WT muscle (p < 0.05). Denervated CTMP-KO gastrocnemius also showed higher Akt and downstream glycogen synthase kinase 3ß (GSK3ß) phosphorylation compared to WT muscle (p < 0.05) as well as ribosomal proteins S6 and 4E-BP1 phosphorylation (p < 0.001 and p < 0.05, respectively). Moreover, CTMP-KO mice showed significantly lower levels of E3 ubiquitin ligase MuRF-1 and myostatin than WT muscle (p < 0.05). Our findings suggest that CTMP is essential to muscle atrophy after denervation and it may act by reducing Akt signaling, protein synthesis, and increasing myocellular catabolism.

A Cost-Effective Analysis of Motivational Interviewing with Palliative Care Versus Usual Care: Results from the Living Well Project.

Little is known about the impact of early palliative care (EPC) combined with motivational interviewing (MI) for persons living with AIDS (PWA). We compared the cost and quality-adjusted life-years (QALYs) of EPC + MI (n = 61) versus usual care (UC) (n = 60) for patients with AIDS, not on antiretroviral medications, enrolled into the Living Well Project trial. Data on clinic, emergency department, and hospital visits were collected through self-report and billing records. Risk-adjusted average annual health care costs were estimated using a generalized linear model with a gamma log-link function. QALYs were calculated using the SF-12v2. Cost-effectiveness was defined as cost per QALY gained. Estimated intervention costs were $165 per participant. EPC + MI reduced costs by 33% (AOR = 0.67; CI 95%: 0.15, 0.93). QALYs did not differ between groups. Results suggest EPC + MI for PWA is cost-saving and maintains quality of life compared to UC due to reduced hospital and ED costs.

Interest in and Uptake of Postabortion Long-Acting Reversible Contraception After Counseling at a Free-Standing Abortion Care Ambulatory Surgery Center, Atlanta, Georgia, 2017‒2018.

We sought to determine the impact of brief previsit counseling on long-acting reversible contraception (LARC) interest and uptake immediately after abortion. We conducted a randomized controlled trial at a free-standing abortion care ambulatory surgery center in metro-Atlanta, Georgia (2017-2018). Among 1270 women, a brief previsit counseling intervention increased interest in LARC by 4.5 percentage points, and interest in LARC after the intervention increased uptake by 9.6 percentage points. Providing brief previsit counseling significantly increased postabortion LARC uptake. (Am J Public Health. 2022;112(9):1257-1260. https://doi.org/10.2105/AJPH.2022.306940).

Environmental Drivers of Gulf Coast Tick (Acari: Ixodidae) Range Expansion in the United States.

In the United States, the Gulf Coast tick (Amblyomma maculatum Koch) is a species of growing medical and veterinary significance, serving as the primary vector of the pathogenic bacterium, Rickettsia parkeri (Rickettsiales: Rickettsiaceae), in humans and the apicomplexan parasite, Hepatozoon americanum, in canines. Ongoing reports of A. maculatum from locations outside its historically reported distribution in the southeastern United States suggest the possibility of current and continuing range expansion. Using an ecological niche modeling approach, we combined new occurrence records with high-resolution climate and land cover data to investigate environmental drivers of the current distribution of A. maculatum in the United States. We found that environmental suitability for A. maculatum varied regionally and was primarily driven by climatic factors such as annual temperature variation and seasonality of precipitation. We also found that presence of A. maculatum was associated with open habitat with minimal canopy cover. Our model predicts large areas beyond the current distribution of A. maculatum to be environmentally suitable, suggesting the possibility of future northward and westward range expansion. These predictions of environmental suitability may be used to identify areas at potential risk for establishment and to guide future surveillance of A. maculatum in the United States.

Academics' Experiences in Veterinary Educational Research: Results of an International Survey.

Research conducted by the veterinary education community is critical to continual improvement of educational outcomes. Additionally, research productivity is one metric in promotion and tenure decisions. We sought to identify challenges encountered or anticipated when undertaking or planning veterinary educational research (VER), to learn how these challenges might be overcome, and to synthesize tips for success from those who have performed VER. A branching survey was developed and deployed along the authors' worldwide veterinary education contacts in a cascading manner. The survey collected quantitative and qualitative information from participants who had performed VER and those who planned to perform VER in the future. The 258 participants represented 41 countries. Of the participants, 204 had performed VER (79%) and 54 planned to in the future (21%). The median time spent teaching was 14 years, and median time performing VER was 5 years. The most commonly reported challenges in performing VER were lack of funding, lack of time, and difficulties encountered when undertaking a study, including data collection, analysis, and publishing. When asked about overcoming the challenges, a major theme emerged around people, who provided expertise and mentoring. The most commonly reported tip for success was collaboration; 73% of experienced researchers reported people as most helpful upon beginning VER. Collaborators provided diverse help with ideas, study design, statistics, and other aspects. These results suggest that institutions can offer support to academics in the form of small grants, protected research time, writing workshops, and mentorship to assist with the production of meaningful VER.

Frailty status predicts futility of cardiopulmonary resuscitation in older adults.

AIM: To determine if frailty is associated with poor outcome following in-hospital cardiac arrest; to find if there is a "frailty threshold" beyond which cardiopulmonary resuscitation (CPR) becomes futile. METHODS: Retrospective review of patients aged over 60 years who received CPR between May 2017 and December 2018, in a tertiary referral hospital, which does not provide primary coronary revascularisation. Clinical Frailty Scale (CFS) and Charlson Comorbidity Index were retrospectively assigned. RESULTS: Data for 90 patients were analysed, the median age was 77 (IQR 70-83); 71% were male; 44% were frail (CFS > 4). Frailty was predictive of in-hospital mortality independent of age, comorbidity and cardiac arrest rhythm (OR 2.789 95% CI 1.145-6.795). No frail patients (CFS > 4) survived to hospital discharge, regardless of cardiac arrest rhythm, whilst 13 (26%) of the non-frail (CFS ≤ 4) patients survived to hospital discharge. Of the 13 survivors (Age 72; range 61-86), 12 were alive at 1 year and had a good neurological outcome, the outcome for the remaining patient was unknown. CONCLUSION: Frail patients are unlikely to survive to hospital discharge following in-hospital cardiac arrest, these results may facilitate clinical decision making regarding whether CPR may be considered futile. The Clinical Frailty Scale is a simple bedside assessment that can provide invaluable information when considering treatment escalation plans, as it becomes more widespread, larger scale observations using prospective assessments of frailty may become feasible.

Association of healthy child-rearing practices and children's receipt of care in patient-centered medical homes.

Efforts to improve the quality of care for children have focused on the patient-centered medical home (PCMH), defined by the National Committee for Quality Assurance (NCQA). Little research has focused on caregivers' role in choosing physicians for children. This study aims to determine whether healthy caregiving behaviors and specific behaviors are associated with children's receipt of PCMH care. Using data from the 2016-2017 National Survey of Children's Health, which includes information on child-rearing behaviors, we estimated logistic regressions, controlling for children's and caregivers' characteristics, to quantify possible associations. We found that each additional healthy child-rearing practice followed increased a child's chance of receiving PCMH care by 4.5% (p < 0.001). Being breastfed (children aged 0-5 years), sharing ideas with their caregiver (children aged 6-17 years), their caregiver ensuring homework is finished (children aged 6-17 years), and having TV time monitored (all ages), each increased the likelihood of PCMH use. These findings show that caregiving behavior is independently associated with locus of care. Future research is warranted as educating caregivers about healthy child-rearing may lead them to seek higher quality care for their children. Also, evaluating the effect of behaviors on health outcomes associated with PCMH would be valuable.

Anaesthetic management and complications of transvascular patent ductus arteriosus occlusion in dogs.

OBJECTIVE: To retrospectively analyse the anaesthetic management, complications and haemodynamic changes in a cohort of dogs undergoing transvascular patent ductus arteriosus (PDA) occlusion in a tertiary referral centre (from January 2017 to August 2018). STUDY DESIGN: Retrospective study. ANIMALS: A total of 49 client-owned dogs. METHODS: Anaesthetic records of dogs with PDA that underwent transvascular occlusion of the ductus were reviewed. Anaesthetic complications evaluated included tachycardia [heart rate (HR) > 160 beats minute-1], bradycardia (HR < 50 beats minute-1), hypertension [systolic arterial pressure (SAP) > 150 mmHg], hypotension [mean arterial pressure (MAP) < 60 mmHg], hypothermia (<37 °C) and the presence of arrhythmias. Cardiovascular variables [HR and invasive SAP, MAP and diastolic arterial pressure (DAP)] at the time of occlusion device deployment (time 0) were compared with variables at 5 and 10 minutes after deployment. Descriptive statistics, Shapiro-Wilk test and repeated measures analysis of variance followed by a Dunnett's post hoc test were used to analyse the data (p < 0.05). RESULTS: Crossbreed dogs were the most commonly represented followed by the Cavalier King Charles Spaniel. The median age was 8 (2-108) months, and female dogs were over-represented (65.3%). The most common American Society of Anesthesiologists score was III. Mean duration of anaesthesia was 96 ± 26 minutes and mean surgery time was 58 ± 21 minutes. Acepromazine with methadone was the most commonly used premedication combination (77.6%). Propofol was the most common induction agent (73.5%). General anaesthesia was maintained with isoflurane in oxygen in all dogs. Complications included hypotension (63%), hypothermia (34%), bradycardia (28%), arrhythmias (16%), hypertension (16%) and haemorrhage (2%). MAP and DAP increased significantly 10 minutes after device deployment compared with time 0. CONCLUSIONS: and clinical relevance: Hypotension was the most common complication reported in dogs undergoing transvascular PDA occlusion. No major adverse events were documented.

The Cost and Public Health System Effects of Active Monitoring and Illness Response for Ebola Virus Disease: A Case Evaluation of Georgia.

In August 2014, the World Health Organization declared the Ebola virus disease epidemic in West Africa a public health emergency of international concern. After 2 imported cases of the disease were identified in the United States in autumn 2014, the Centers for Disease Control and Prevention recommended that all jurisdictions begin active monitoring of travelers at risk of developing Ebola virus disease for 21 days from the last day of a potential exposure to minimize the risk of disease transmission. Here we describe the infrastructure development, monitoring processes, total planned expenditures, and effects on the public health system in Georgia associated with active monitoring and illness response of all travelers from Ebola-affected West African countries from October 2014 to March 2016. We conducted qualitative interviews with Georgia Department of Public Health (GDPH) staff. We identified state active monitoring and illness response infrastructure investments and monitoring activities and state and federal funds spent in both areas. And, we evaluated whether active monitoring and illness response enhanced Georgia's ability to respond to future infectious disease outbreaks. Developing the infrastructure to support the monitoring and response required investment in information technology, training of public health and medical personnel, increasing laboratory capacity, and securing personal protective equipment. Estimated total expenditures were $8.25 million, with 76% spent on infrastructure and 17% on daily monitoring. The GDPH leveraged internal resources and partnerships to implement active monitoring and illness response. Infrastructure investment increased surveillance capacity, strengthened relationships between the GDPH and medical providers, and led to the creation of infectious disease transport and hospital networks. Active monitoring and illness response increased outbreak preparedness, but it warrants comparison with other possible responses to determine its overall value.