Pseudoreticulocytosis by the ADVIA 2120 Hematology Analyzer and Other Hematologic Changes in a Cynomolgus Macaque (Macaca fascicularis) With Malaria.

Important hematologic changes can be observed in nonhuman primates with malaria, including inaccurate reticulocyte counts by the ADVIA 2120 hematology analyzer. A 5-year-old male purpose-bred cynomolgus macaque (Macaca fascicularis) imported from a commercial source in Cambodia was enrolled in a nonclinical toxicity study investigating the effects of an immunomodulatory pharmaceutical agent. On study day 22, an increase in large unstained cells (LUCs), due to increased monocytes (2.20 × 103/µl, reference interval: 0.17-0.76 × 103/µl), was reported by the analyzer during a scheduled hematologic evaluation, which prompted blood smear review and revealed that the macaque had a high burden of Plasmodium spp.. The macaque did not have clinical signs for the infection at this time point. Progressively higher parasite burdens and persistently increased monocytes (markedly increased by study day 56, 10.38 × 103/µl) were observed at subsequent hematologic evaluations. New Methylene Blue stain manual reticulocyte counts were performed on study day 43 and at later time points, and showed that the analyzer reported erroneous higher reticulocyte counts (study day 43: +6.7%, +266.2 × 109/L; study day 50: +18.9%, +409.8 × 109/L) compared with the manual reticulocyte counts (pseudoreticulocytosis). The magnitude of regenerative response was considered inadequate for the severity of anemia at these time points. Atypical reticulocyte scatter plot distributions from the analyzer were also observed at time points with high parasite burdens, and combined with increased LUCs, may suggest high burden parasitemia. Verification of automated reticulocyte counts is important in cases with high malarial parasite burdens and the recognition of pseudoreticulocytosis is prudent in assessing appropriateness of the regenerative response. Increases in monocytes correlated with higher parasite burdens and marked increases may be an indicator of advanced disease.

Quantifying Novice and Expert Differences in Visual Diagnostic Reasoning in Veterinary Pathology Using Eye-Tracking Technology.

Visual diagnostic reasoning is the cognitive process by which pathologists reach a diagnosis based on visual stimuli (cytologic, histopathologic, or gross imagery). Currently, there is little to no literature examining visual reasoning in veterinary pathology. The objective of the study was to use eye tracking to establish baseline quantitative and qualitative differences between the visual reasoning processes of novice and expert veterinary pathologists viewing cytology specimens. Novice and expert participants were each shown 10 cytology images and asked to formulate a diagnosis while wearing eye-tracking equipment (10 slides) and while concurrently verbalizing their thought processes using the think-aloud protocol (5 slides). Compared to novices, experts demonstrated significantly higher diagnostic accuracy (p <.017), shorter time to diagnosis (p <.017), and a higher percentage of time spent viewing areas of diagnostic interest (p <.017). Experts elicited more key diagnostic features in the think-aloud protocol and had more efficient patterns of eye movement. These findings suggest that experts' fast time to diagnosis, efficient eye-movement patterns, and preference for viewing areas of interest supports system 1 (pattern-recognition) reasoning and script-inductive knowledge structures with system 2 (analytic) reasoning to verify their diagnosis.

EVALUATION OF THE I-STAT PORTABLE CLINICAL ANALYZER FOR MEASUREMENT OF IONIZED CALCIUM AND SELECTED BLOOD CHEMISTRY VALUES IN ASIAN ELEPHANTS (ELEPHAS MAXIMUS).

Thei-STAT® portable clinical analyzer (PCA) provides patient-side results for hematologic, biochemical, and blood gas values when immediate results are desired. This analyzer is commonly used in nondomestic animals; however, validation of this method in comparison with traditional benchtop methods should be performed for each species. In this study, the i-STAT PCA was compared with the Radiometer ABL 800 Flex benchtop analyzer using 24 heparinized whole blood samples obtained from healthy E. maximus . In addition, the effect of sample storage was evaluated on the i-STAT PCA. Analytes evaluated were hydrogen ion concentration (pH), glucose, potassium (K+), sodium (Na+), bicarbonate (HCO3-), total carbon dioxide (TCO2), partial pressure of carbon dioxide (PCO2), and ionized calcium (iCa2+). Statistical analysis using correlation coefficients, Passing-Bablok regression analysis, and Bland-Altman plots found good agreement between results from samples run immediately after phlebotomy and 4 hr postsampling on the i-STAT PCA with the exception of K+, which is known to change with sample storage. Comparison of the results from the two analyzers at 4 hr postsampling found very strong or strong correlation in all values except K+, with statistically significant bias in all values except glucose and PCO2. Despite bias, mean differences assessed via Bland-Altman plots were clinically acceptable for all analytes excluding K+. Within the reference range for iCa2+, the iCa2+ values obtained by the i-STAT PCA and Radiometer ABL 800 Flex were close in value, however in light of the constant and proportionate biases detected, overestimation at higher values and underestimation at lower values of iCa2+ by the i-STAT PCA would be of potential concern. This study supports the use of the i-STAT PCA for the evaluation of these analytes, with the exception of K+, in the Asian elephant.

HEPATIC OSTEODYSTROPHY IN A GOLDEN LION TAMARIN (LEONTOPITHECUS ROSALIA).

An 8-yr-old, captive, female golden lion tamarin ( Leontopithecus rosalia ) with a 6-yr history of hyperbilirubinemia was examined for inappetence and weight loss. Physical examination and blood pressure monitoring under anesthesia revealed hypothermia and hypotension, and blood work revealed hypoglycemia, markedly elevated liver enzymes, including serum alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase, and confirmed the hyperbilirubinemia. A complete blood count suggested chronic lymphoid leukemia. The animal's condition deteriorated during recovery, and the animal died despite aggressive treatment. Grossly, there was micronodular cirrhosis of the liver, severe icterus, and diffuse osteopenia of all examined bones. Microscopic examination of the liver confirmed the micronodular cirrhosis and bone lesions were compatible with diffuse osteopenia and osteomalacia. This brief communication presents a case of chronic liver disease and lesions indicative of metabolic bone disease, also known as hepatic osteodystrophy. To the authors' knowledge, this is the first documented case of hepatic osteodystrophy in the veterinary literature.

Use of a Tourniquet by LIFE STAR Air Medical Crew: A Case Report.

For many years tourniquets were perceived as dangerous due to the belief that they led to loss of limb because of ischemia. Their use in civilian and military environments was discouraged. Emergency medical responders were not taught about tourniquets and commercial tourniquets were not available. However, research by the United States military during the wars in Iraq and Afghanistan has demonstrated that tourniquets are safe life-saving devices. As a consequence, they have been widely deployed in combat situations and there are now calls for the use of tourniquets in the civilian prehospital setting. This article presents a report of the successful application of a tourniquet by the LIFE STAR crew to control bleeding that local emergency medical services (EMS) personnel could not control with direct pressure. Tourniquets should be readily available in public places and carried by all EMS.

Educational interventions to improve cytology visual diagnostic reasoning measured by eye tracking.

The teaching of visual diagnostic reasoning skills, to date, has been conducted in a largely unstructured apprenticeship manner. The purpose of this study was to assess if the introduction of two educational interventions improved the visual diagnostic reasoning skills of novices. These were (1) the active use of key diagnostic features and (2) image repetition. A pre-test and post-test research design was used to compare the two teaching interventions to a traditional teaching group and an expert group using eye tracking as an assessment method. The time to diagnosis and the percentage of time spent viewing an area of diagnostic interest (AOI) were compared using independent t-tests, paired t-tests, and analysis of covariance (ANCOVA). Diagnostic accuracy as a dichotomous variable was compared using Chi-square tables. Students taught in an active-learning manner with image repetition behaved most like experts, with no significant difference from experts for percentage of time spent in the AOIs and a significantly faster time to diagnosis than experts (p<.017). Our results from the educational interventions suggest a greater level of improvement in the eye tracking of students that were taught key diagnostic features in an active-learning forum and were shown multiple case examples.

Pseudo-hypoproteinemia in a hyperbilirubinemic dog with immune-mediated hemolytic anemia.

A 10-year-old spayed female Miniature Poodle was presented to the University of Georgia veterinary teaching hospital for evaluation of lethargy, vomiting and anorexia of 4 days' duration. Physical examination, history and a minimum database led to a diagnosis of immune-mediated hemolytic anemia accompanied by marked hyperbilirubinemia. Refractometric protein determination was within the reference interval, whereas the biuret method indicated hypoproteinemia. This discrepancy was attributed to interference of bilirubin and biliverdin with the spectrophotometric read-out of the biuret total protein assay. The albumin concentration, determined by bromcresol green, and refractometric total protein were less affected by this interference.

Reference intervals for select hematologic and plasma biochemical analytes of wild Lake Sturgeon (Acipenser fulvescens) from the St. Lawrence River in New York.

BACKGROUND: Lake Sturgeon (Acipenser fulvescens) is a long-lived freshwater fish distributed throughout the Great Lakes region and is a threatened species in New York State. The species' unique life cycle makes it useful as an indicator of ecosystem health, and efforts to repatriate Lake Sturgeon to their historic range are underway. However, comprehensive hematologic and biochemical reference intervals that would be valuable for assessing the health status of individual animals have not been reported. OBJECTIVES: The objective of this study was to determine normal hematologic and plasma biochemical reference intervals for healthy wild Lake Sturgeon. METHODS: Blood samples were collected from 52 wild Lake Sturgeon caught in gill nets in the St. Lawrence River. Heparinized whole blood and plasma samples were analyzed using standard techniques. Reference intervals were calculated using the robust method following elimination of outliers and Box-Cox transformation of data. RESULTS: Hematologic reference intervals were as follows: PCV 17-38%, estimated WBC count 2740-23,150/µL, neutrophils 193-6121/µL, eosinophils 0-558/µL, other granulocytes/heterophils 0-488/µL, lymphocytes 1447-14,044/µL, and monocytes 55-1684/µL. Plasma biochemical reference intervals were as follows: aspartate aminotransferase 333-1746 U/L, calcium 1.85-2.80 mmol/L, chloride 95-123 mmol/L, creatine kinase 776-35,536 U/L, glucose 2.94-14.76 mmol/L, glutamate dehydrogenase 6-30 U/L, phosphate 2.03-5.81 mmol/L, potassium 2.34-4.24 mmol/L, sodium 122.9-151.1 mmol/L, total protein 2.0-4.4 g/dL, triglycerides 1.07-5.12 mmol/L, and uric acid 1-251 µmol/L. CONCLUSION: Reference intervals reported here will be useful for health assessment of wild and repatriated Lake Sturgeon.

Comparison of select hematology and serum chemistry analtyes between wild-caught and aquarium-housed lake sturgeon (Acipenser fulvescens).

Hematology and serum chemistry analytes were compared between wild-caught and aquarium-housed lake sturgeon (Acipenser fulvescens) to potentially improve understanding of medical issues in lake sturgeon. Blood samples were taken from 30 lake sturgeon exhibited in 11 institutions in the United States and from 23 experimentally stocked lake sturgeon caught in gill nets in the lower Genesee River in Rochester, New York, USA. For hematology, only segmented neutrophil count was significantly different, with wild-caught fish having a higher number of circulating neutrophils. For clinical chemistry analytes, chloride, uric acid, calcium, phosphate, glucose, aspartate aminotransferase, triglycerides, and creatine kinase were significantly different between the two cohorts. These differences are likely not clinically significant and are attributable to handling stress, variability in environmental parameters, or differences in nutritional status. This is the first report of hematology and serum chemistry values in aquarium-housed lake sturgeon and provides useful reference intervals for clinicians.

Diagnosis of Borrelia-associated uveitis in two horses.

Borrelia burgdorferi, the etiologic agent of Lyme disease is a tick born spirochetal infection. Clinical signs of Lyme borreliosis are uncommon in horses, but when present they are often vague and nonspecific. In horses, Lyme borreliosis has been implicated in musculoskeletal, neurological, reproductive, and ocular disorders, including uveitis, but definitive diagnosis can be challenging as the causative agent is rarely isolated and serologic tests can be unreliable and do not confirm active disease. Here, we report two cases of equine uveitis associated with B. burgdorferi based on the identification of spirochetes within ocular fluids and confirmed with PCR testing. The two cases illustrate some of the challenges encountered in the recognition and diagnosis of equine Lyme borreliosis. Although only one of many possible causes of equine uveitis, Lyme disease should be considered a differential diagnosis, especially in endemic areas. Given the possibility for false negative results of serum tests during uveitis associated with B. burgdorferi and the failure of such tests to confirm active infection, a combination of cytologic assessment, antibody, and/or PCR testing of ocular fluids may be worthwhile if the clinical suspicion for Lyme uveitis is high.

Animals as sentinels for human lead exposure: a case report.

Because human and nonhuman animals often share the same environment, there is potential concurrent exposure to toxicants. As a result, domestic animals can be used as sentinels for exposure of people to these agents. Here we present a case illustrating exposure of both humans and domestic animals to lead contamination in their environments. This case study occurred at a farm where cattle deaths were determined to have been caused by lead poisoning based on elevated postmortem tissue lead concentrations. Elevated blood lead concentrations were detected in the remaining cattle, a dog, a cat, and a pregnant woman (37.3 µg/dL) living on the farm. The range of blood lead concentrations in the domestic animals was 8.42 (cat) to 85.41 µg/dL (calf), although clinical signs of lead poisoning were not apparent in these animals. Further testing revealed the most likely source for lead exposure to be paint in the barn and home. Household dogs and cats have been used as sentinels for lead poisoning in humans, but cattle may also act as a sentinel species for environmental lead contamination.

Anticoagulant-dependent in vitro hemagglutination in a cat.

A 17-year-old domestic shorthaired cat was presented to the Cornell University Hospital for Animals for recheck of hyperthyroidism previously treated with radioiodine. Marked agglutination was noted in a blood sample collected into EDTA for a CBC; no other clinical or hematologic evidence of hemolysis was observed and none developed despite persistent agglutination in additional EDTA samples collected over a 2-month period. Blood drawn into heparin and sodium citrate tubes did not have grossly or microscopically detectable agglutination, unless EDTA was added. Plasma from the cat induced agglutination of washed RBCs from a control cat in the presence of EDTA but not in the presence of heparin. Flow cytometric analysis of samples created by mixing plasma from the patient with washed RBCs from a control cat showed immunoglobulin coating of the control RBCs, predominantly by IgM. These findings suggested an anticoagulant-dependent antibody-mediated mechanism for the agglutination. EDTA-dependent hemagglutination has not been reported previously in cats, although rare cases have been described in humans. The phenomenon needs to be recognized as an in vitro occurrence in order to prevent erroneous diagnosis of immune-mediated hemolytic anemia.

Practical management of dyslipidemia with elevated lipoprotein(a).

OBJECTIVE: To report a case and describe a practical approach to treating dyslipidemia in a very-high-risk patient with elevated lipoprotein(a) [Lp(a)]. SETTING: Pharmacist-managed lipid clinic, from November 2006 to July 2007. PATIENT DESCRIPTION: A 50-year-old white woman with a recent history of multiple myocardial infarctions presented for management of dyslipidemia. CASE SUMMARY: At baseline, the patient had elevated low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), total cholesterol (TC), and Lp(a) (306 nmol/L) levels and low high-density lipoprotein cholesterol (HDL-C) levels. Early initiation of combination therapy with a statin and niacin extended release (ER) titration was started. After 3 months, despite progressive weight gain caused by dietary indiscretion, LDL-C decreased by 24% and TG and TC levels reached goal. Lp(a) levels did not change. Niacin ER titration continued, pravastatin was maximized, and ezetimibe 10 mg daily was started. Despite dramatic 9-month weight gain (68 lb total), LDL-C and HDL-C reached goal and Lp(a) levels decreased by 33% (204 nmol/L) after niacin ER maximization. RESULTS: Lp(a) is an emerging risk factor in cardiovascular disease (CVD). Elevated Lp(a) (>30 mg/dL) has been implicated as both an independent and an additive risk factor for CVD and stroke, particularly in women. In this case, the patient did not reach the optimal goal (<30 mg/dL) but did experience more than 30% reduction in Lp(a) levels. Although multiple factors, including subclinical hypothyroidism, hormonal changes, and renal disease, increase Lp(a) levels, few beneficial treatment options exist (i.e., estrogen and niacin). Although the exact mechanism of action is unknown, niacin ER has been documented to reduce Lp(a) by 36% to 38%. Some effect of ezetimibe on Lp(a) in this patient cannot be ruled out. CONCLUSION: This case illustrates a practical use of currently available therapy options to address Lp(a) as a secondary cardiovascular risk factor. Niacin is a preferred option for Lp(a) lowering in very-high-risk patients with coronary heart disease and dyslipidemia. The importance of moderate reductions in Lp(a) is not known.

Errors in the heat of battle: taking a closer look at shared cognition breakdowns through teamwork.

OBJECTIVE: We developed a theoretically based taxonomy for classifying shared cognition breakdowns related to teamwork which contribute to fratricide incidents. BACKGROUND: Fratricide on the battlefield is an inescapable cost of war. A number of technological advancements have been made in terms of combat identification systems to reduce the risk of these incidents. However, fratricide continues to occur at alarming rates. METHOD: We take a human-centered approach to understanding errors leading to fratricide incidents by focusing on shared cognition. We turn to the literature and provide the theoretical foundations for an error classification taxonomy to improve understanding of why fratricide incidents occur. RESULTS: Based on our review of the literature, we identified a number of problem areas leading to fratricide incidents. However, many of the cited contributing factors were broad terms (e.g., poor coordination) and did little to tell us why the breakdown occurred and where improvements are needed. Therefore, we chose to focus on one specific area--teamwork breakdowns--and discuss in depth how these breakdowns contribute to fratricide. CONCLUSION: In this paper, we take a first step toward proposing a taxonomy that allows for the diagnostic assessment of what causes teamwork breakdowns in fratricide. We understand that a taxonomy is only as good as the data available and encourage richer case studies from which to learn. APPLICATION: To apply this taxonomy in an operational setting, we provide a set of behavioral markers that can be used to identify teamwork breakdowns on the battlefield.

Using simulation-based training to improve patient safety: what does it take?

BACKGROUND: Through simulations health care workers can learn by practicing skills taught and experiencing mistakes before interacting with an actual patient. A number of areas within the health care industry are currently using simulation-based training to help individuals and teams improve patient safety. WHAT IS SIMULATION-BASED TRAINING? The key components of simulation-based training are as follows: performance history/skill inventory, tasks/competencies, training objectives, events/exercises, measures/metrics, performance diagnosis, and feedback and debrief. WHAT DOES IT TAKE FOR SIMULATION-BASED TRAINING TO BE EFFECTIVE? To be effective, simulation-based training must be implemented appropriately. The guidelines are as follows: understand the training needs and requirements; instructional features, such as performance measurement and feedback, must be embedded within the simulation; craft scenarios based on guidance from the learning outcomes; create opportunities for assessing and diagnosing individual and/or team performance within the simulation; guide the learning; focus on cognitive/psychological simulation fidelity; form a mutual partnership between subject matter experts and learning experts; and ensure that the training program worked. CONCLUSION: The health care community can gain significantly from using simulation-based training to reduce errors and improve patient safety when it is designed and delivered appropriately.