Correction to: Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial).

Following the publication of this article [1], the authors reported a number of errors which are given below.

Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial).

BACKGROUND: Improving the quality and safety of perioperative care is a global priority. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was a stepped-wedge cluster randomised trial of a quality improvement (QI) programme to improve 90-day survival for patients undergoing emergency abdominal surgery in 93 hospitals in the UK National Health Service. METHODS: The aim of this process evaluation is to describe how the EPOCH intervention was planned, delivered and received, at both cluster and local hospital levels. The QI programme comprised of two interventions: a care pathway and a QI intervention to aid pathway implementation, focussed on stakeholder engagement, QI teamwork, data analysis and feedback and applying the model for improvement. Face-to-face training and online resources were provided to support senior clinicians in each hospital (QI leads) to lead improvement. For this evaluation, we collated programme activity data, administered an exit questionnaire to QI leads and collected ethnographic data in six hospitals. Qualitative data were analysed with thematic or comparative analysis; quantitative data were analysed using descriptive statistics. RESULTS: The EPOCH trial did not demonstrate any improvement in survival or length of hospital stay. Whilst the QI programme was delivered as planned at the cluster level, self-assessed intervention fidelity at the hospital level was variable. Seventy-seven of 93 hospitals responded to the exit questionnaire (60 from a single QI lead response on behalf of the team); 33 respondents described following the QI intervention closely (35%) and there were only 11 of 37 care pathway processes that > 50% of respondents reported attempting to improve. Analysis of qualitative data suggests QI leads were often attempting to deliver the intervention in challenging contexts: the social aspects of change such as engaging colleagues were identified as important but often difficult and clinicians frequently attempted to lead change with limited time or organisational resources. CONCLUSIONS: Significant organisational challenges faced by QI leads shaped their choice of pathway components to focus on and implementation approaches taken. Adaptation causing loss of intervention fidelity was therefore due to rational choices made by those implementing change within constrained contexts. Future large-scale QI programmes will need to focus on dedicating local time and resources to improvement as well as on training to develop QI capabilities. EPOCH TRIAL REGISTRATION: ISRCTN80682973 https://doi.org/10.1186/ISRCTN80682973 Registered 27 February 2014 and Lancet protocol 13PRT/7655.

Epidemiological survey of Angiostrongylus vasorum in dogs and slugs around a new endemic focus in Scotland.

The nematode parasite Angiostrongylus vasorum is an increasingly important cause of respiratory and other diseases in dogs. Geographical spread from previously limited endemic foci has occurred rapidly. This paper investigates parasite epidemiology around the location of the first reported case in Scotland in 2009: by detection of A vasorum-specific DNA in gastropod intermediate hosts, and in dogs circulating DNA and specific antibodies, and first stage larvae in faeces. Overall prevalence in gastropods was 6.7 per cent (16/240), with parasite DNA found in slugs in the Arion ater and Arion hortensis species aggregates and the snail Helix aspersa (syn. Cornu aspersum). Of 60 dogs presenting with clinical signs compatible with angiostrongylosis, none tested positive using PCR on peripheral blood or Baermann test on faeces, and none of 35 tested for circulating anti-A vasorum antibodies were positive. PCR prevalence in gastropods was highest (11 per cent) in the park frequented by the canine angiostrongylosis index case. Molecular survey for infection in gastropods is a potentially informative and efficient method for characterising the distribution of A vasorum and therefore local risk of canine infection. However, there appears to be a complex relationship between prevalence in gastropods and emergence of canine clinical disease, which requires further work to advance understanding of parasite transmission and geographical disease spread.

A quantitative release assessment for the noncommercial movement of companion animals: risk of rabies reintroduction to the United kingdom.

In 2004, the European Union (EU) implemented a pet movement policy (referred to here as the EUPMP) under EU regulation 998/2003. The United Kingdom (UK) was granted a temporary derogation from the policy until December 2011 and instead has in place its own Pet Movement Policy (Pet Travel Scheme (PETS)). A quantitative risk assessment (QRA) was developed to estimate the risk of rabies introduction to the UK under both schemes to quantify any change in the risk of rabies introduction should the UK harmonize with the EU policy. Assuming 100 % compliance with the regulations, moving to the EUPMP was predicted to increase the annual risk of rabies introduction to the UK by approximately 60-fold, from 7.79 × 10(-5) (5.90 × 10(-5), 1.06 × 10(-4)) under the current scheme to 4.79 × 10(-3) (4.05 × 10(-3), 5.65 × 10(-3)) under the EUPMP. This corresponds to a decrease from 13,272 (9,408, 16,940) to 211 (177, 247) years between rabies introductions. The risks associated with both the schemes were predicted to increase when less than 100 % compliance was assumed, with the current scheme of PETS and quarantine being shown to be particularly sensitive to noncompliance. The results of this risk assessment, along with other evidence, formed a scientific evidence base to inform policy decision with respect to companion animal movement.

Angiostrongylus vasorum infection in dogs: Presentation and risk factors.

Infection with the nematode Angiostrongylus vasorum is an emerging cause of canine disease in Europe and part of North America, yet published data on its epidemiology in endemic areas are lacking. This study tested faecal samples from 897 dogs attending veterinary practices in the southern part of Great Britain, a long standing endemic focus. Among 790 dogs presenting with respiratory or other signs broadly suggestive of angiostrongylosis, 16% tested positive on a single Baermann's examination, compared with 2% of healthy dogs in the same catchment areas. Risk factors for positive tests included age (higher risk in younger dogs), season (more cases earlier in the calendar year), and worming history (lower risk if given milbemycin oxime in the past 12 weeks). Sex, neutering status and breed were not significant in terms of risk of testing positive. The most common clinical signs in infected dogs were respiratory, along with non-specific signs such as lethargy and exercise intolerance, while bleeding, neurological and gastrointestinal signs were also recorded. Around half the dogs sampled that showed signs of extra-pulmonary disease also had respiratory signs. Direct faecal smears and Baermann's tests read after one hour detected 56% and 83% of diagnosed cases respectively. The data confirm that A. vasorum is commonly associated with disease in endemic areas, which manifests with a broad range of signs at primary care level. Information on risk factors is useful in diagnosis and control, and forms a basis for further epidemiological investigation.

Real-time and multiplex real-time polymerase chain reactions for the detection of Bartonella henselae within cat flea, Ctenocephalides felis, samples.

Bartonella henselae (Rhizobiales: Bartonellacae), the agent of cat-scratch disease, is an emerging bacterial pathogen which can be transmitted via infective faecal material of Ctenocephalides felis Bouché (Siphonaptera: Pulicidae). Worldwide, B. henselae has been identified in 1-53% of felines and 2.9-17.4% of fleas. Although culture is the routine method for detection, the procedure is time-consuming and is rarely used for isolation directly from flea vectors. The current study reports the development of a quantitative real-time polymerase chain reaction (qPCR) to detect and quantify B. henselae organisms from vector samples. The qPCR is specific and detects as few as 2.5 genome copies. To enable direct quantification of Bartonella organisms in different vector samples, we developed a qPCR to detect C. felis DNA that also acts as an extraction control. Combining both PCRs into a multiplex format validates B. henselae results when sampling flea populations, although there is a reduction in sensitivity. This reduction might be counteracted by a different combination of probe fluorophores.

The development of a qPCR assay to detect tick (Ixodida) DNA and its implementation for the study of tick-borne pathogen transmission.

Polymerase chain reaction (PCR) analysis is regularly used to detect pathogens within arthropod vectors, but has also been applied to investigate vector DNA. This study details a novel highly sensitive quantitative PCR (qPCR) which detects and quantifies DNA from Ixodes ricinus, the European vector of Anaplasma phagocytophilum. By pairing this with a qPCR to detect A. phagocytophilum, valid comparisons of pathogen load can be made between different sized tick-tissue samples. These qPCRs were validated in I. ricinus that were fed A. phagocytophilum-infected blood using an artificial membrane feeder. Pathogens were detected in the tick haemolymph within 36h, indicating that successful infection had taken place. This study illustrates the application of vector-targeted qPCRs to confirm and validate pathogen load in samples as part of investigations of vector-pathogen interactions.

Elucidating the spread of the emerging canid nematode Angiostrongylus vasorum between Palaearctic and Nearctic ecozones.

Angiostrongylus vasorum is an emerging parasite that is currently distributed through Western Europe and parts of South America. An isolated population is also present in Newfoundland, Canada. This presents a risk of onward spread into North America, but its origin is unknown. To ascertain the phylogeographic relationships and genetic diversity of A. vasorum within the western Palaearctic and eastern Nearctic ecozones, a total of 143 adult and larval nematode specimens were collected from foxes (Vulpes vulpes) and dogs (Canis lupus familiaris) in Canada, Denmark, France, Germany, Ireland, the Netherlands, Portugal and the United Kingdom, and a coyote (Canis latrans) in Canada. DNA was extracted and the second internal transcribed spacer and two mitochondrial loci were amplified and sequenced. Multiple haplotypes (n=35) based on combined mitochondrial sequences (1078bp) of the partial cytochrome oxidase subunit I (COI), large subunit ribosomal RNA (rrnL) and the complete nicotinamide adenine dinucleotide dehydrogenase 3 (NADH3) sequences, were observed throughout the Palaearctic countries sampled; however, only a single haplotype was observed for the Canadian A. vasorum population. The likely origin of A. vasorum in Newfoundland is therefore inferred to be within the western Palaearctic. There was no evidence of genetic segregation of parasites in dogs, foxes and coyotes, supporting the hypothesis that transmission occurs between wild and domestic canids. The transmission dynamics and population structure of this nematode are further discussed.

A SYBR green real-time PCR assay for the detection of the nematode Angiostrongylus vasorum in definitive and intermediate hosts.

The parasitic nematode Angiostrongylus vasorum is an emerging challenge for companion animal and wildlife health, with reported increases in both distribution and incidence in Europe. To facilitate improved detection of this parasite, a SYBR green real-time polymerase chain reaction (PCR) was developed to amplify a region of the second internal transcribed spacer (ITS-2) of A. vasorum from both definitive and intermediate host samples. The PCR assay was capable of detecting a single of plasmid DNA containing the entire ITS-2 region, a single first stage larva (L1) in 200 microl canine EDTA blood, a single L1 in 200 mg of canine faeces and a single L3 in 10mg of Biomphalaria glabrata tissue. The assay exhibited a high level of specificity to A. vasorum and whilst it potentially amplifies DNA of other Angiostrongylus species, it did not amplify DNA from a range of other common canine parasitic nematodes. Field evaluation of the PCR assay was conducted by screening canine EDTA blood and faecal samples from suspected cases of A. vasorum infection and compared with Baermann's detection, and also by screening a range of gastropod species from an endemic area. Real-time quantitative PCR offers a more efficient means of detecting A. vasorum infection with a lower limit of detection than traditional diagnostic tests, and it therefore has important clinical and epidemiological applications.

Angiostrongylus vasorum from South America and Europe represent distinct lineages.

Angiostrongylus vasorum is a nematode parasite of sylvan and domestic species of the family Canidae. It has a broad but patchy distribution worldwide, and there is evidence for geographical spread and increasing incidence of infection in recent years. While historically Angiostrongylus-like nematodes identified in dogs and foxes have been described as A. vasorum in Europe and Angiocaulus raillieti in South America, more recent taxonomic revision has amalgamated these into a single species, A. vasorum. Here we report, for the first time, the molecular characterization of isolates of A. vasorum from Germany, Portugal, Denmark and the United Kingdom on the basis of the mitochondrial COI gene and the second ribosomal internal transcribed spacer. When compared with isolates from Brazil, sequence analysis revealed 2 distinct genotypes. Estimated rates of evolution based on COI sequences for both nematode and host are consistent with the hypothesis that the presence of A. vasorum in South America is a result of an ancient evolutionary event. Angiostrongylus vasorum in South America potentially represents a separate species to that observed in Europe.

Polarized gamma-ray emission from the crab.

Pulsar systems accelerate particles to immense energies. The detailed functioning of these engines is still poorly understood, but polarization measurements of high-energy radiation may allow us to locate where the particles are accelerated. We have detected polarized gamma rays from the vicinity of the Crab pulsar using data from the spectrometer on the International Gamma-Ray Astrophysics Laboratory satellite. Our results show polarization with an electric vector aligned with the spin axis of the neutron star, demonstrating that a substantial fraction of the high-energy electrons responsible for the polarized photons are produced in a highly ordered structure close to the pulsar.

Molecular evidence of tick-transmitted infections in dogs and cats in the United Kingdom.

PCR analysis was used to determine the prevalence of tick-transmitted infections in 120 systemically ill dogs and 60 cats recruited over a period of three months from 52 veterinary practices in the UK. The animals had not travelled outside the UK and had one or more of the following clinical criteria: acute or recurrent pyrexia, anaemia and/or thrombocytopenia, polyarthritis/muscle pain, splenomegaly/lymphadenopathy, and intraocular inflammation with systemic signs. Blood samples from the animals were tested for the presence of DNA from Borrelia burgdorferi sensu lato and Anaplasma phagocytophilum by using simple PCR targeting. B. burgdorferi sensu lato was detected in five dogs and two cats, and A. phagocytophilum was detected in one dog and one cat. These results provide the first molecular evidence of naturally occurring B. burgdorferi sensu lato infection in cats in the UK and confirm that A. phagocytophilum infection is present in cats. There were no statistically significant associations between the infections and the clinical signs shown by the dogs and cats.

Imaging electron interferometer.

An imaging interferometer was created in a two-dimensional electron gas by reflecting electron waves emitted from a quantum point contact with a circular mirror. Images of electron flow obtained with a scanning probe microscope at liquid He temperatures show interference fringes when the mirror is energized. A quantum phase shifter was created by moving the mirror via its gate voltage, and an interferometric spectrometer can be formed by sweeping the tip over many wavelengths. Experiments and theory demonstrate that the interference signal is robust against thermal averaging.

Infections of the subcutis and skin of dogs caused by rapidly growing mycobacteria.

Nine dogs with panniculitis due to rapidly growing mycobacteria (RGM) were examined over 17 years. Dogs were two to 15 years; five were male, four were female. All were obese or in good condition. Antecedent injury, typically a dog bite or vehicular trauma, could be identified in some patients, while one bitch had hyperadrenocorticism. Infections involved different locations, although the cervicothoracic region, dorsum or flank were most often affected. Patients were systemically well, apart from one dog with pyrexia and two with pain or lameness. Cytology demonstrated pyogranulomatous inflammation, but in only one case was it possible to see acid-fast bacilli (AFB) in smears. Histology demonstrated chronic active pyogranulomatous panniculitis and dermatitis; AFB could be detected in only four specimens. Culture of aspirates or resected tissues demonstrated RGM in all cases, comprising six Mycobacterium smegmatis group and three Mycobacterium fortuitum group isolates. Resection of infected tissues, perioperative injectable antimicrobials and long courses of oral antimicrobials chosen according to susceptibility data generally effected a cure, although some cases recurred.

Pathogen carriage by the cat flea Ctenocephalides felis (Bouché) in the United Kingdom.

The carriage of Bartonella, Rickettsia felis and haemoplasma species was investigated in cat fleas (Ctenocephalides felis) collected from 121 cats and dogs in the United Kingdom. DNA extracted from fleas was analysed using genus and species-specific PCR and amplicons were characterised using DNA sequencing. Fifty percent of flea samples were PCR positive for at least one pathogen. Twenty one percent were positive for R. felis, 17% for Bartonella henselae, 40% for haemoplasma species and 20% were infected with more than one of the pathogen species studied. It is clear from the results in this study that companion cats and dogs are commonly infested with Ct. felis carrying bacterial pathogens of significance to human and animal health. These findings raise the possibility that Ct. felis found on dogs and cats are a potential source of infection with such pathogens for humans.