Experimental infection of aquatic bird bornavirus 1 in domestic chickens.

Aquatic bird bornavirus 1 (ABBV-1), classified in the Orthobornavirus genus, is a neurotropic virus that infects wild waterfowl causing persistent infection of the nervous system. Given the conspicuous presence of wild waterfowl in urban areas and farmlands, spillover of this virus into domesticated poultry species is a concern. The goal of this study was to test the ability of ABBV-1 to infect and cause disease in chickens. Two day-old, White Leghorn chickens (n, 176) were inoculated with ABBV-1 through the oral, intramuscular, or intracranial routes, and sampled at 1, 4, 8, and 12-weeks post infection (wpi) to assess virus replication and lesion development. Chickens became infected only through the intracranial and intramuscular routes, developing earliest infection in the brain by 1 wpi (intracranial group), and spinal cord by 8 wpi (intramuscular group). Except for the kidney of one bird in the intracranial group, no other tissues (including choanal and cloacal swabs) tested positive for the virus. Therefore, while the virus could reach the central nervous tissue (CNS) from the muscle in approximately 20% of birds (centripetal spread), it inefficiently reached peripheral sites after replication in the CNS (centrifugal spread). Inflammation in the CNS was observed in the intracranial and intramuscular groups starting at 8 and 12 wpi, respectively, and consisted of mononuclear perivascular cuffing. This is the first study to document the susceptibility of chickens to ABBV-1 infection, and indicates that this species can become infected with ABBV-1, although less extensively than what is observed in waterfowl. This suggests that ABBV-1 replication is partially restricted in gallinaceous birds.

Early Diagnosis of Primary Immunodeficiency Disease Using Clinical Data and Machine Learning.

BACKGROUND: Primary immunodeficiency diseases (PIDD) are a group of immune-related disorders that have a current median delay of diagnosis between 6 and 9 years. Early diagnosis and treatment of PIDD has been associated with improved patient outcomes. OBJECTIVE: To develop a machine learning model using elements within the electronic health record data that are related to prior symptomatic treatment to predict PIDD. METHODS: We conducted a retrospective study of patients with PIDD identified using inclusion criteria of PIDD-related diagnoses, immunodeficiency-specific medications, and low immunoglobulin levels. We constructed a control group of age-, sex-, and race-matched patients with asthma. The primary outcome was the diagnosis of PIDD. We considered comorbidities, laboratory tests, medications, and radiological orders as features, all before diagnosis and indicative of symptom-related treatment. Features were presented sequentially to logistic regression, elastic net, and random forest classifiers, which were trained using a nested cross-validation approach. RESULTS: Our cohort consisted of 6422 patients, of whom 247 (4%) were diagnosed with PIDD. Our logistic regression model with comorbidities demonstrated good discrimination between patients with PIDD and those with asthma (c-statistic: 0.62 [0.58-0.65]). Adding laboratory results, medications, and radiological orders improved discrimination (c-statistic: 0.70 vs 0.62, P < .001), sensitivity, and specificity. Extending to the advanced machine learning models did not improve performance. CONCLUSIONS: We developed a prediction model for early diagnosis of PIDD using historical data that are related to symptomatic care, which has potential to fill an important need in reducing the time to diagnose PIDD, leading to better outcomes for immunodeficient patients.

Experimental infection of aquatic bird bornavirus in Muscovy ducks.

Aquatic bird bornavirus (ABBV-1), an avian bornavirus, has been reported in wild waterfowl from North America and Europe that presented with neurological signs and inflammation of the central and peripheral nervous systems. The potential of ABBV-1to infect and cause lesions in commercial waterfowl species is unknown. The aim of this study was to determine the ability of ABBV-1 to infect and cause disease in day-old Muscovy ducks (n = 174), selected as a representative domestic waterfowl. Ducklings became infected with ABBV-1 through both intracranial and intramuscular, but not oral, infection routes. Upon intramuscular infection, the virus spread centripetally to the central nervous system (brain and spinal cord), while intracranial infection led to virus spread to the spinal cord, kidneys, proventriculus, and gonads (centrifugal spread). Infected birds developed both encephalitis and myelitis by 4 weeks post infection (wpi), which progressively subsided by 8 and 12 wpi. Despite development of microscopic lesions, clinical signs were not observed. Only five birds had choanal and/or cloacal swabs positive for ABBV-1, suggesting a low potential of Muscovy ducks to shed the virus. This is the first study to document the pathogenesis of ABBV-1 in poultry species, and confirms the ability of ABBV-1 to infect commercial waterfowl.

Development and external validation of prediction models for adverse health outcomes in rheumatoid arthritis: A multinational real-world cohort analysis.

BACKGROUND: Identification of rheumatoid arthritis (RA) patients at high risk of adverse health outcomes remains a major challenge. We aimed to develop and validate prediction models for a variety of adverse health outcomes in RA patients initiating first-line methotrexate (MTX) monotherapy. METHODS: Data from 15 claims and electronic health record databases across 9 countries were used. Models were developed and internally validated on Optum® De-identified Clinformatics® Data Mart Database using L1-regularized logistic regression to estimate the risk of adverse health outcomes within 3 months (leukopenia, pancytopenia, infection), 2 years (myocardial infarction (MI) and stroke), and 5 years (cancers [colorectal, breast, uterine] after treatment initiation. Candidate predictors included demographic variables and past medical history. Models were externally validated on all other databases. Performance was assessed using the area under the receiver operator characteristic curve (AUC) and calibration plots. FINDINGS: Models were developed and internally validated on 21,547 RA patients and externally validated on 131,928 RA patients. Models for serious infection (AUC: internal 0.74, external ranging from 0.62 to 0.83), MI (AUC: internal 0.76, external ranging from 0.56 to 0.82), and stroke (AUC: internal 0.77, external ranging from 0.63 to 0.95), showed good discrimination and adequate calibration. Models for the other outcomes showed modest internal discrimination (AUC < 0.65) and were not externally validated. INTERPRETATION: We developed and validated prediction models for a variety of adverse health outcomes in RA patients initiating first-line MTX monotherapy. Final models for serious infection, MI, and stroke demonstrated good performance across multiple databases and can be studied for clinical use. FUNDING: This activity under the European Health Data & Evidence Network (EHDEN) has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 806968. This Joint Undertaking receives support from the European Union's Horizon 2020 research and innovation programme and EFPIA.

Histological and histochemical characteristics of lacrimal glands in beluga whales (Delphinapterus leucas).

The objective of this study was to describe the histological and histochemical characteristics of the lacrimal glands of beluga whales. The study was carried out on the formalin-fixed ocular globes from 96 carcasses of beluga whales found stranded in the St. Lawrence estuary in Quebec, Canada. Hematoxylin and eosin (H&E) stained slides from the eyes of each whale were examined for lacrimal glands. Histological description was done with H&E and Masson Trichrome (MT) stains. Period Acid-Schiff (PAS), Alcian blue (AB) pH 1.0 and 2.5, and High Iron Diamine (HID) stains were used for histochemical characterization of glycoproteins. Thirteen ocular samples from animals ranging from neonate to 48 y included sections of lacrimal glands. The H&E stain revealed a tubuloalveolar gland architecture, separated into lobules by dense connective tissue. Each lobule contained a mixture of acini and tubules with ductules. Small and large acini were composed of low and tall columnar cells, respectively. Acinar cells contained basophilic cytoplasmic granules. The ductules were lined with a bi-layered cuboidal-to-squamous epithelium. The MT stain highlighted the connective tissue separating ductules and acini. Large acini were positive for PAS and some small acini had patchy uptake. Positive staining for AB pH 1.0 and 2.5 was mainly seen in tall columnar cells as compared to small acini that had faint to no stain uptake. High Iron Diamine stain revealed 90% staining of all acinar cells, with 10% exhibiting a mixed blue-black tinge. It was concluded that the lacrimal glands of beluga whales have similar histological and histochemical findings to those of artiodactyla and carnivora orders.

L'objectif de cette étude était de décrire les caractéristiques histologiques et histochimiques des glandes lacrymales des bélugas. L'étude a été réalisée sur les globes oculaires fixés au formol de 96 carcasses de bélugas trouvées échouées dans l'estuaire du Saint-Laurent au Québec, Canada. Des lames colorées à l'hématoxyline et à l'éosine (H&E) des yeux de chaque baleine ont été examinées pour la présence de glandes lacrymales. La description histologique a été réalisée avec des colorations H&E et trichrome de Masson (MT). Les colorations Periodic acid-Schiff (PAS), au bleu Alcian (AB) pH 1,0 et 2,5, et diamine à haute teneur en fer (HID) ont été utilisées pour la caractérisation histochimique des glycoprotéines. Treize échantillons oculaires provenant d'animaux allant du nouveau-né à 48 ans comprenaient des sections de glandes lacrymales. La coloration H&E a révélé une architecture de glande tubulo-alvéolaire, séparée en lobules par un tissu conjonctif dense. Chaque lobule contenait un mélange d'acini et de tubules avec des ductules. Les petits et les grands acini étaient respectivement composés de cellules cylindriques basses et hautes. Les cellules acinaires contenaient des granules cytoplasmiques basophiles. Les canaux étaient tapissés d'un épithélium cuboïde à squameux bicouche. La coloration MT a mis en évidence le tissu conjonctif séparant les canaux et les acini. Les grands acini étaient positifs pour le PAS et certains petits acini avaient une absorption inégale. Une coloration positive pour AB pH 1,0 et 2,5 a été principalement observée dans les cellules cylindriques hautes par rapport aux petits acini qui avaient une absorption de coloration faible ou nulle. La coloration HDI a révélé une coloration de 90 % de toutes les cellules acinaires, 10 % présentant une teinte mixte bleu-noir. Il a été conclu que les glandes lacrymales des bélugas présentent des résultats histologiques et histochimiques similaires à ceux des ordres des artiodactyles et des carnivores.(Traduit par Docteur Serge Messier).

Predictors of chronic opioid therapy in Medicaid beneficiaries with HIV who initiated antiretroviral therapy.

The factors associated with chronic opioid therapy (COT) in patients with HIV is understudied. Using Medicaid data (2002-2009), this retrospective cohort study examines COT in beneficiaries with HIV who initiated standard combination anti-retroviral therapy (cART). We used generalized estimating equations on logistic regression models with backward selection to identify significant predictors of COT initiation. COT was initiated among 1014 out of 9615 beneficiaries with HIV (male: 10.4%; female: 10.7%). Those with older age, any malignancy, Hepatitis C infection, back pain, arthritis, neuropathy pain, substance use disorder, polypharmacy, (use of) benzodiazepines, gabapentinoids, antidepressants, and prior opioid therapies were positively associated with COT. In sex-stratified analyses, multiple predictors were shared between male and female beneficiaries; however, chronic obstructive pulmonary disease, liver disease, any malignancy, and antipsychotic therapy were unique to female beneficiaries. Comorbidities and polypharmacy were important predictors of COT in Medicaid beneficiaries with HIV who initiated cART.

Signal Detection and Methodological Limitations in a Real-World Registry: Learnings from the Evaluation of Long-Term Safety Analyses in PSOLAR.

INTRODUCTION: Psoriasis Longitudinal Assessment and Registry (PSOLAR) was designed in 2007 as the first disease-based registry for patients with psoriasis. OBJECTIVE: The aim of this study was to discuss methodological limitations and post hoc analyses in long-term safety registries using learnings from analyses of a potential safety risk for major adverse cardiovascular events (MACE) in PSOLAR. METHODS: PSOLAR is an international observational study of over 12,000 psoriasis patients that was conducted to meet postmarketing safety commitments for infliximab and ustekinumab. A recent annual review of registry data indicated a potential MACE risk for ustekinumab vs. non-biologics based on prespecified COX model regression analyses, which yielded an adjusted hazard ratio (HR) of 1.533 (95% confidence interval [CI] 1.103-2.131). Therefore, we conducted a comprehensive review of key statistical methodology and implemented post hoc analytical methods to address specific limitations. RESULTS: The following limiting factors were identified: (1) inclusion of both prevalent and incident (new) users of biologics; (2) unanticipated imbalances in patient characteristics between treatment cohorts at baseline; (3) limited availability of relevant clinical data after enrollment; and (4) divergence of characteristics associated with outcomes among comparator groups over time. The analysis was modified to include only incident users, propensity scores were used to weight HRs, and adalimumab was deemed a more clinically appropriate comparator. The revised HR was 0.820 (95% CI 0.532-1.265), indicating no meaningful increase in MACE risk for ustekinumab. CONCLUSION: Our results, which do not support a causal association between ustekinumab exposure and MACE risk, underscore the need for ongoing assessment of analytical methods in long-term observational studies.

Alpha-1 Antitrypsin Deficiency-Associated Clinical Manifestations and Healthcare Resource Use in the United States.

Pulmonary events (PEs) associated with alpha-1 antitrypsin deficiency (AATD) can have a severe clinical course and increase healthcare resource use (HRU). However, AATD-associated HRU and healthcare costs have not been extensively described. This study describes and compares real-world HRU and healthcare costs among US patients with severe (requiring hospitalization after AATD-related PE) versus nonsevere AATD clinical course. Administrative healthcare claims for patients with a second primary AATD diagnosis between 6/1/2008 and 12/31/2017 were analyzed from 2 databases (requiring continuous enrollment 6 months preceding diagnosis). Patient baseline characteristics and AATD-associated PE incidence rates, HRU, and healthcare costs during follow-up were compared in patients with severe versus nonsevere AATD. Of 5109 patients with a second AATD diagnosis, 2674 (severe, n = 711 [26.6%]; nonsevere, n = 1963 [73.4%]) had ≥1 AATD-associated PE. PE incidence per 100 person-years was higher in patients with severe versus nonsevere AATD. Annual incidences (mean ± SD) of emergency department (1.2 ± 5.7 vs. 0.4 ± 1.2), inpatient (1.3 ± 2.5 vs. 0.1 ± 0.5), and outpatient (10.3 ± 15.9 vs. 5.7 ± 13.2) visits were higher in patients with severe versus nonsevere AATD. Median (interquartile range) annual costs were also higher for patients with severe versus nonsevere AATD for emergency department ($185 [$0-$1665] vs. $0 [$0-$264]), inpatient ($16,038 [$2968-$70,941] vs. $0 [$0-$0]), and outpatient ($2663 [$412-$10,277] vs. $1114 [$134-$4195]) visits. Higher percentages of patients with severe AATD were prescribed augmentation therapy, antibiotics, or corticosteroids. These findings suggest that patients with severe AATD have higher incidence of AATD-associated PEs, as well as higher HRU and healthcare costs.

Leveraging unstructured data to identify hereditary angioedema patients in electronic medical records.

BACKGROUND: The epidemiologic impact of hereditary angioedema (HAE) is difficult to quantify, due to misclassification in retrospective studies resulting from non-specific diagnostic coding. The aim of this study was to identify cohorts of patients with HAE-1/2 by evaluating structured and unstructured data in a US ambulatory electronic medical record (EMR) database. METHODS: A retrospective feasibility study was performed using the GE Centricity EMR Database (2006-2017). Patients with ≥ 1 diagnosis code for HAE-1/2 (International Classification of Diseases, Ninth Revision, Clinical Modification 277.6 or International Classification of Diseases, Tenth Revision, Clinical Modification D84.1) and/or ≥ 1 physician note regarding HAE-1/2 and ≥ 6 months' data before and after the earliest code or note (index date) were included. Two mutually exclusive cohorts were created: probable HAE (≥ 2 codes or ≥ 2 notes on separate days) and suspected HAE (only 1 code or note). The impact of manually reviewing physician notes on cohort formation was assessed, and demographic and clinical characteristics of the 2 final cohorts were described. RESULTS: Initially, 1691 patients were identified: 190 and 1501 in the probable and suspected HAE cohorts, respectively. After physician note review, the confirmed HAE cohort comprised 254 patients and the suspected HAE cohort decreased to 1299 patients; 138 patients were determined not to have HAE and were excluded. The overall false-positive rate for the initial algorithms was 8.2%. Across final cohorts, the median age was 50 years and > 60% of patients were female. HAE-specific prescriptions were identified for 31% and 2% of the confirmed and suspected HAE cohorts, respectively. CONCLUSIONS: Unstructured EMR data can provide valuable information for identifying patients with HAE-1/2. Further research is needed to develop algorithms for more representative HAE cohorts in retrospective studies.

Incidence of von Willebrand disease in Denmark, 1995-2016: A cohort study.

INTRODUCTION: Information about temporal development of von Willebrand disease (VWD) incidence at a population level is scarce. To our knowledge, no study has described the incidence of VWD at a population level. AIM: To estimate overall and annual incidence rates of hospital diagnosed VWD in Denmark between 1995 and 2016 as well as the frequency of hospital treated bleeding episodes before and after VWD diagnosis. METHODS: A registry-based cohort study that included all Danish patients with a first diagnosis of VWD in Denmark, identified in the Danish National Patient Registry through 1995-2016. RESULTS: We identified 1,035 patients with a diagnosis of VWD. The overall incidence rate of VWD in 1995-2016 was 8.6 (95% CI: 8.1-9.2). The annual age-standardized incidence rate per 100 000 person-years varied between 4.1 (95% CI: 2.4-5.9) in 1998 and 16.7 (95% CI: 13.1-20.3) in 2005. A prominent peak in rates appeared from 2002 to 2008. One and five years before VWD diagnosis, 6% and 11.5% of the patients had at least one hospital treated bleeding episode. One and five years after diagnosis, the corresponding percentages were 7.9% and 13.4%. CONCLUSION: These results are the first population-based estimates of VWD incidence. The incidence may be underestimated because asymptomatic individuals may not be diagnosed. The observed peak in incidence from 2002-2008 may be explained by increased medical attention, leading to more patients being diagnosed, rather than an actual increase in VWD incidence. However, overall, we observed no systematic changes in VWD incidence over the study period.

Molecular approach to the classification of chronic fibrosing lung disease-there and back again.

Chronic diffuse parenchymal lung disease (DPLD) is an umbrella term for a very heterogeneous group of lung diseases. Over the last decades, clinical, radiological and histopathological criteria have been established to define and separate these entities. More recently the clinical utility of this approach has been challenged as a unifying concept of pathophysiological mechanisms and a shared response to therapy across the disease spectrum have been described. In this review, we discuss molecular motifs for subtyping and the prediction of prognosis focusing on genetics and markers found in the blood, lavage and tissue. As a purely molecular classification so far lacks sufficient sensitivity and specificity for subtyping, it is not routinely used and not implemented in international guidelines. However, a better molecular characterization of lung disease with a more precise identification of patients with, for example, a risk for rapid disease progression would facilitate more accurate treatment decisions and hopefully contribute to better patients' outcomes.

piNET-An Automated Proliferation Index Calculator Framework for Ki67 Breast Cancer Images.

In this work, a novel proliferation index (PI) calculator for Ki67 images called piNET is proposed. It is successfully tested on four datasets, from three scanners comprised of patches, tissue microarrays (TMAs) and whole slide images (WSI), representing a diverse multi-centre dataset for evaluating Ki67 quantification. Compared to state-of-the-art methods, piNET consistently performs the best over all datasets with an average PI difference of 5.603%, PI accuracy rate of 86% and correlation coefficient R = 0.927. The success of the system can be attributed to several innovations. Firstly, this tool is built based on deep learning, which can adapt to wide variability of medical images-and it was posed as a detection problem to mimic pathologists' workflow which improves accuracy and efficiency. Secondly, the system is trained purely on tumor cells, which reduces false positives from non-tumor cells without needing the usual pre-requisite tumor segmentation step for Ki67 quantification. Thirdly, the concept of learning background regions through weak supervision is introduced, by providing the system with ideal and non-ideal (artifact) patches that further reduces false positives. Lastly, a novel hotspot analysis is proposed to allow automated methods to score patches from WSI that contain "significant" activity.

Diagnosis and long-term management of post-traumatic seizures in a white-crowned pionus (Pionus senilis).

CASE DESCRIPTION: A 13-year-old female white-crowned pionus (Pionus senilis) was examined because of seizures 22 months after it was treated for a traumatic brain injury (TBI) characterized by vision loss, hemiparesis, nystagmus, circling, and head tilt. CLINICAL FINDINGS: Bloodwork performed during the initial seizure workup revealed hypercalcemia and hypercholesterolemia, which were attributed to vitellogenesis given the bird's previous egg-laying history and recent onset of reproductive behavior. Magnetic resonance imaging of the brain revealed diffuse right pallium atrophy with multifocal hydrocephalus ex vacuo, which were believed to be the result of the previous TBI. Findings were most consistent with post-traumatic seizures (PTS). TREATMENT AND OUTCOME: Levetiracetam (100 mg/kg [45 mg/lb], PO, q 12 h) was initiated for PTS management. A 4.7-mg deslorelin implant was injected SC to suppress reproductive behavior. The bird was reexamined for presumed status epilepticus 5 times over 22 months. Seizure episodes coincided with onset of reproductive behavior. The levetiracetam dosage was increased (150 mg/kg [68 mg/lb], PO, q 8 h), and zonisamide (20 mg/kg [9.1 mg/lb], PO, q 12 h) was added to the treatment regimen. Additional deslorelin implants were administered every 2 to 6 months to suppress reproductive behavior. The owner was trained to administer midazolam intranasally or IM as needed at home. The treatment regimen helped control but did not eliminate seizure activity. The bird was euthanized 22 months after PTS diagnosis for reasons unrelated to the TBI or PTS. CLINICAL RELEVANCE: Long-term management of PTS in a pionus was achieved with levetiracetam and zonisamide administration.

Masking in Pragmatic Trials: Who, What, and When to Blind.

Masking (or blinding) of treatment assignment is routinely implemented in classical randomized clinical trials (RCTs) to isolate the effect of the intervention itself and to minimize the potential for bias that could occur with traditional trials. Such biases could be introduced with the conduct, assessment of endpoints, management of conditions, analysis, and reporting when the treatment assignments are known. However, masking of treatments is not only complex but it hinders how generalizable the findings are to the "real world" clinical setting. Pragmatic RCTs (pRCTs) are intended to evaluate the effects of interventions within routine medical care, and as such, do not typically mask treatment groups; moreover, pRCTs assess comparators that are available in routine medical practice, not masked placebos. Whether pRCTs should be masked if intended for regulatory or other purposes has recently been questioned. The literature on pRCTs, while extensive, does not address how much actual benefit is gained from masking outcomes and how masking may affect the "real world" nature of a study. Here, we propose an approach to evaluate sources of bias, describe stakeholders in the conduct of pRCTs who are most likely affected, and offer a framework for considering how masking may be implemented effectively while maintaining generalizability.

Alveolar echinococcosis in an Ontario dog resembling an hepatic abscess.

A boxer dog was evaluated because of lethargy, vomiting, and abdominal pain. Ultrasonography revealed multiple cystic structures in the abdomen. Exploratory laparotomy revealed 3 well-encapsulated hepatic masses and abdominal effusion with suppurative inflammation. Collectively, these findings suggested the hepatic masses were most likely abscesses. However, histologic examination of the hepatic masses revealed multi-cystic structures, consistent with alveolar echinococcosis. The diagnosis was confirmed by DNA sequencing. The dog was treated with daily albendazole, but within a few weeks exhibited adverse side effects. After 6 months, the dog's condition deteriorated, and it was euthanized.

Échinococcose alvéolaire ressemblant à un abcès hépatique chez un chien en Ontario. Un chien de race boxer fut évalué à cause de léthargie, vomissements, et douleur abdominale. Une échographie révéla de multiples structures kystiques dans l'abdomen. Une laparotomie exploratoire révéla trois masses hépatiques bien encapsulées et une effusion abdominale avec inflammation suppurative. Collectivement, ces données suggéraient que les masses hépatiques étaient fort probablement des abcès. Toutefois, l'examen histologique des masses hépatiques révéla des structures multi-kystiques, compatibles avec une échinococcose alvéolaire. Le diagnostic fut confirmé par séquençage d'ADN. Le chien fut traité avec de l'albendazole quotidiennement, mais en quelques semaines il montra des signes d'effets adverses. Après 6 mois la condition du chien se détériora et il fut euthanasié.(Traduit par Dr Serge Messier).

IHC Color Histograms for Unsupervised Ki67 Proliferation Index Calculation.

Automated image analysis tools for Ki67 breast cancer digital pathology images would have significant value if integrated into diagnostic pathology workflows. Such tools would reduce the workload of pathologists, while improving efficiency, and accuracy. Developing tools that are robust and reliable to multicentre data is challenging, however, differences in staining protocols, digitization equipment, staining compounds, and slide preparation can create variabilities in image quality and color across digital pathology datasets. In this work, a novel unsupervised color separation framework based on the IHC color histogram (IHCCH) is proposed for the robust analysis of Ki67 and hematoxylin stained images in multicentre datasets. An "overstaining" threshold is implemented to adjust for background overstaining, and an automated nuclei radius estimator is designed to improve nuclei detection. Proliferation index and F1 scores were compared between the proposed method and manually labeled ground truth data for 30 TMA cores that have ground truths for Ki67+ and Ki67- nuclei. The method accurately quantified the PI over the dataset, with an average proliferation index difference of 3.25%. To ensure the method generalizes to new, diverse datasets, 50 Ki67 TMAs from the Protein Atlas were used to test the validated approach. As the ground truth for this dataset is PI ranges, the automated result was compared to the PI range. The proposed method correctly classified 74 out of 80 TMA images, resulting in a 92.5% accuracy. In addition to these validations experiments, performance was compared to two color-deconvolution based methods, and to six machine learning classifiers. In all cases, the proposed work maintained more consistent (reproducible) results, and higher PI quantification accuracy.

Klossiella equi Infecting Kidneys of Ontario Horses: Life Cycle Features and Multilocus Sequence-Based Genotyping Confirm the Genus Klossiella Belongs In the Adeleorina (Apicomplexa: Coccidia).

Species in the genus Klossiella Smith and Johnson, 1902 are unique among the suborder Adeleorina because they are monoxenous in mammals exclusively, whereas all other reported members of the Adeleorina use invertebrates as definitive hosts. Unlike other coccidia, all members of the Adeleorina undergo syzygy, the association of microgamonts and macrogamonts before maturation to gametes and syngamy. After fertilization, many members of the Adeleorina produce thin-walled polysporocystic oocysts. Despite being biologically similar to other members of the Adeleorina, the phylogenetic placement of the genus Klossiella has been questioned based on its unique host affinity. In the present study, 2 cases of Klossiella equi were reported from the kidneys of horses in Ontario. Details of the life cycle as well as mitochondrial and nuclear 18S ribosomal DNA ( 18S rDNA) sequences were analyzed to provide both morphological and molecular evidence for the phylogenetic placement of K. equi. Initially, various stages of the life cycle were identified in histological slides prepared from the kidney tissue, and DNA was isolated from the infected tissue. Polymerase chain reaction and Sanger sequencing were used to generate a complete mitochondrial genome sequence (6,569 bp) and a partial 18S rDNA sequence (1,443 bp). The K. equi 18S rDNA sequence was aligned with various publicly available apicomplexan 18S rDNA sequences. This alignment was used to generate a phylogenetic tree based on Bayesian inference. Multiple K. equi stages were identified including meronts, microgamonts, and macrogamonts associating in syzygy as well as thin-walled oocysts in various stages of sporogonic development. The 18S rDNA sequence of K. equi positioned within the monophyletic Adeleorina clade. The mitochondrial genome of K. equi contained 3 coding sequences for cytochrome c oxidase I, cytochrome c oxidase III, and cytochrome b as well as various fragmented ribosomal sequences. These components were arranged in a unique order that has not been observed in other apicomplexan mitochondrial genomes sequenced to date. Overall, it was concluded that there were sufficient morphological and molecular data to confirm the placement of K. equi and the genus Klossiella among the Adeleorina. The biological and molecular data obtained from these cases may assist with future studies evaluating the prevalence and life history of this seemingly underreported parasite and better define the impact of K. equi on the health of domestic and wild equids.

ECHINOCOCCUS EQUINUS HYDATID CYST IN THE LIVER OF A PRZEWALSKI'S HORSE ( EQUUS PRZEWALSKII) IN A CANADIAN ZOO.

A 23-yr-old captive-born Przewalski's horse mare ( Equus przewalskii) was euthanized at a Canadian zoo because of severe colic resulting from rupture of a jejunal pseudodiverticulum. An incidental finding of an encysted larval cestode within a hepatic granuloma was diagnosed on histopathology. Gel-based polymerase chain reaction (PCR) on liver tissue was positive for Echinococcus granulosus sensu lato, and deoxyribonucleic acid sequencing of the PCR product was 100% homologous with Echinococcus equinus. This appears to be the first molecular confirmation of E. equinus in North America, and the first report of cystic echinococcosis in a Przewalski's horse.

Real-World Evidence: What It Is and What It Can Tell Us According to the International Society for Pharmacoepidemiology (ISPE) Comparative Effectiveness Research (CER) Special Interest Group (SIG).

On December 8, 2016, the New England Journal of Medicine published a sounding board on Real World Evidence (RWE)1 by the US Food and Drug Administration (FDA) leadership. While the value of RWE based on nonrandomized observational studies was appreciated, such as for hypothesis generating, safety, and measuring quality in healthcare delivery, the authors expressed concerns on the quality of data sources and the ability of methodologies to control for confounding. In response, we offer a few considerations regarding these concerns.

Speaking Up: Veterinary Ethical Responsibilities and Animal Welfare Issues in Everyday Practice.

Although expectations for appropriate animal care are present in most developed countries, significant animal welfare challenges continue to be seen on a regular basis in all areas of veterinary practice. Veterinary ethics is a relatively new area of educational focus but is thought to be critically important in helping veterinarians formulate their approach to clinical case management and in determining the overall acceptability of practices towards animals. An overview is provided of how veterinary ethics are taught and how common ethical frameworks and approaches are employed-along with legislation, guidelines and codes of professional conduct-to address animal welfare issues. Insufficiently mature ethical reasoning or a lack of veterinary ethical sensitivity can lead to an inability or difficulty in speaking up about concerns with clients and ultimately, failure in their duty of care to animals, leading to poor animal welfare outcomes. A number of examples are provided to illustrate this point. Ensuring that robust ethical frameworks are employed will ultimately help veterinarians to "speak up" to address animal welfare concerns and prevent future harms.