Multi-pathogen serological survey of migratory caribou herds: A snapshot in time.

Pathogens can impact host survival, fecundity, and population dynamics even when no obvious disease is observed. Few baseline data on pathogen prevalence and diversity of caribou are available, which hampers our ability to track changes over time and evaluate impacts on caribou health. Archived blood samples collected from ten migratory caribou herds in Canada and two in Greenland were used to test for exposure to pathogens that have the potential to effect population productivity, are zoonotic or are emerging. Relationships between seroprevalence and individual, population, and other health parameters were also examined. For adult caribou, the highest overall seroprevalence was for alphaherpesvirus (49%, n = 722), pestivirus (49%, n = 572) and Neospora caninum (27%, n = 452). Lower seroprevalence was found for parainfluenza virus type 3 (9%, n = 708), Brucella suis (2%, n = 758), and Toxoplasma gondii (2%, n = 706). No animal tested positive for antibodies against West Nile virus (n = 418) or bovine respiratory syncytial virus (n = 417). This extensive multi-pathogen survey of migratory caribou herds provides evidence that caribou are exposed to pathogens that may have impacts on herd health and revealed potential interactions between pathogens as well as geographical differences in pathogen exposure that could be linked to the bio-geographical history of caribou. Caribou are a keystone species and the socio-economic cornerstone of many indigenous cultures across the North. The results from this study highlight the urgent need for a better understanding of pathogen diversity and the impact of pathogens on caribou health.

Polypharmacy Rates among Patients over 45 years

Polypharmacy, defined as receipt of ≥5 medications in any one month, is often associated with potentially inappropriate prescribing and adverse drug interactions. High levels of polypharmacy have been observed internationally and in Ireland. The Health Service Executive Primary Care Reimbursement Services (HSE-PCRS) pharmacy claims database for the GMS eligible population was used. We conducted Chi-square tests to determine the statistical significance of perceived differences in medication use among patients aged ³ 45 years. Our results establish a national benchmark for polypharmacy in gender and various age categories in the HSE-PCRS. Of the 794,628 individuals aged ≥45 years with at least one claim in 2013, 64.3% (510,946) had polypharmacy, with higher rates among women (67.0% - 293,886 - compared to 60.8% of men - 216,444). Patients aged 45-54 years were less likely to have polypharmacy (38.6% - 69,934) compared to those aged 75 years old (82.6% - 197,565). The high levels of polypharmacy are of interest, and suggest that monitoring and evaluation of patients' medication regimes may be required to ensure appropriateness.

Comparative study of OMNIgene®â€¢SPUTUM reagent versus cold-chain for the transportation of sputum samples to GeneXpert®MTB/RIF testing sites in Malawi.

BACKGROUND: The study was conducted in a remote sputum sample collection sites and GeneXpert® MTB/RIF testing centers to detect Mycobacterium tuberculosis in Malawi. The main purpose of the study was to evaluate whether sputum samples stored and transported with OMNIgene®â€¢SPUTUM (OM-S) medium perform comparably to the routine cold-chain stored and transported samples for GeneXpert testing to detect Mycobacterium tuberculosis. METHODS: Two sputum samples from each of 362 tuberculosis suspects were randomly assigned to the OMNIgene treated (OM-S group) or the standard-of-care group (SOC; transported via cold chain). All specimens were tested at regional GeneXpert testing sites using the expectorated (raw) sputum protocol. Demographic, clinical, transport/storage and Xpert data were recorded for each specimen pair. Agreement between the SOC and OM-S groups' Xpert results was evaluated using Cohen's kappa analysis. RESULTS: Mean patient age was 42.3 years (range 2-79 years), 77% of patients were female, and 80% were HIV-positive. Mean transport/storage time was 6.7 days (range, 0-29 days). The rates of MTB positivity for the OM-S and SOC groups were comparable (11.8 and 11.2%, respectively), inter-test agreement was "very good" (κ = 0.97), and overall percent agreement was 99%. Two specimen pairs (both mucoid, one 13 days transport, one 1 day transport) had discordant Xpert results. CONCLUSION: OM-S-treated sputum specimens can undergo multi-day ambient-temperature storage as well as transport and yield Xpert results comparable to those of cold-chain-transported samples in Malawi.

Investigation of OMNIgene·SPUTUM performance in delayed tuberculosis testing by smear, culture, and Xpert MTB/RIF assays in Uganda.

OMNIgene·SPUTUM (OM-S) is a sample transport reagent designed to work with all tuberculosis diagnostics while eliminating the need for cold chain. OM-S-treated sputum samples were assayed in several tests after multiday holds. Raw sputa from 100 patients underwent direct smear microscopy, were manually split and assigned to the OM-S group [OM-S added at collection (no other processing required) and tested after 0- to 5-day holds at room temperature] or standard-of-care (SOC) group (NaOH/N-acetyl l-cysteine decontamination, all tested on day of collection). Concentrated smear microscopy, Lowenstein Jensen (LJ) culture, and mycobacteria growth indicator tube (MGIT) culture were performed. For patients with negative direct smear, a second sample was split, with SOC (raw sputum) and OM-S portions (sediment) tested in the Xpert MTB/RIF (Xpert) assay. OM-S group and SOC group results were strongly concordant on all four tests [range, 89% (MGIT)-97% (Xpert)]. OM-S MGIT, LJ, and Xpert tests were in statistical agreement with SOC MGIT as reference. OM-S specimens had lower culture contamination rates (3% vs. 10% LJ; 2% vs. 5% MGIT) but required, on average, 5.6 additional days to become MGIT-positive. The findings suggest that samples held/transported in OM-S are compatible with smear microscopy, LJ or MGIT culture, and Xpert, and perform comparably to fresh sputum samples. Larger feasibility studies are warranted.

Evaluation of OMNIgene®â€¢SPUTUM-stabilised sputum for long-term transport and Xpert® MTB/RIF testing in Nepal.

SETTING: German Nepal TB Project, National Tuberculosis Reference Laboratory, Kathmandu, Nepal. OBJECTIVE: To evaluate whether transporting samples in OMNIgene®â€¢SPUTUM (OM-S) reagent from a peripheral collection site to a central laboratory in Nepal can improve tuberculosis (TB) detection and increase the sensitivity of Xpert® MTB/RIF testing. DESIGN: One hundred sputum samples were split manually. Each portion was assigned to the OM-S group (OM-S added at collection, airline-couriered without cold chain, no other processing required) or the standard-of-care (SOC) group (samples airline-couriered on ice, sodium hydroxide + N-acetyl-L-cysteine processing required at the laboratory). Smear microscopy and Xpert testing were performed. RESULTS: Transport time was 2-13 days. Overall smear results were comparable (respectively 58% and 56% smear-negative results in the OM-S and SOC groups). The rate of smear-positive, Mycobacterium tuberculosis-positive (MTB+) sample detection was identical for both treatment groups, at 95%. More smear-negative MTB+ samples were detected in the OM-S group (17% vs. 13%, P = 0.0655). CONCLUSION: Sputum samples treated with OM-S can undergo multiday ambient-temperature transport and yield comparable smear and Xpert results to those of SOC samples. Further investigation with larger sample sizes is required to assess whether treating sputum samples with OM-S could increase the sensitivity of Xpert testing in smear-negative samples.

Translocated dogs from Nunavut and the spread of rabies.

BACKGROUND: Investigations of rabid animals that cross provincial/territorial boundaries are resource intensive and complex because of their multi-jurisdictional and multi-sectoral nature. OBJECTIVE: To describe the multi-jurisdictional responses to two unrelated rabid puppies originating from Nunavut. METHODS: A descriptive summary of the investigations following the identification of a rabid puppy in Alberta (August 2013) and another in Saskatchewan (December 2014). RESULTS: These investigations involved public health and agriculture authorities in five provinces/territories, as well as the Canadian Food Inspection Agency (CFIA). In Alberta, a puppy who became ill after being transported by air from Nunavut was euthanized and diagnosed with rabies (Arctic fox variant). Eighteen individuals were assessed for exposure to rabies; nine received rabies post-exposure prophylaxis (RPEP). An exposed household dog that tested negative was electively euthanized. In Nunavut, the rabid puppy's mother and litter mates were placed under quarantine. In Saskatchewan, another puppy became ill during transit by air from Nunavut. It was subsequently euthanized and diagnosed with rabies (Arctic fox variant). Two of three Saskatchewan individuals, including a veterinary technician, received RPEP. Two Nova Scotia residents were exposed to the puppy while in Nunavut and received RPEP. One household dog received booster vaccination, was quarantined for 45 days and remained asymptomatic. In Nunavut, the rabid puppy's mother and litter mates were not identified. In both cases, exposure to an Arctic fox was the probable source of rabies in the puppies. CONCLUSION: Translocation of dogs from the north where Arctic fox rabies is endemic poses a risk to human and animal health and may negatively impact control of rabies in Canada. There is currently no national framework to prevent inter-jurisdictional movement of potentially rabid animals in Canada.

Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign.

PURPOSE: Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively. METHOD: A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction. RESULTS: Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001). DISCUSSION: Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.

An audit of a steriod withdrawal regimen in cardiac transplantation patients.

BACKGROUND: Heart transplantation is optimal treatment for many patients with end-stage heart failure. Current data report 1-year graft survival rates of 85% after transplantation. The success of transplantation in large part is attributable to immunosuppression, including steroids, one of the mainstay agents. Despite its efficacy to treat acute graft rejection, steroids show numerous adverse effects. With newer immunosuppressive agents, steroid withdrawal is possible. MATERIAL AND METHODS: We compared cardiac transplant patients who died versus survived between 2001 and 2006. We obtained Personal, transplant, occurrence of and cause of death data as well as postoperative intervals. Steroid therapy details were gathered, particularly whether the patient had been weaned off these agents. We calculated steroid doses and steroid-free years, as well as the steroid therapy status of posttransplant patients who remained alive in 2006. RESULTS: Fifty cardiac transplant patients died between 2001 and 2006 excluding 6 who had graft failure and 2 who died of multiorgan failure before initial discharge. Of the 42 patient who died, 29 (69%) were on and 13 (31%) had been withdrawn from steroid therapy at time of death. There were 132 posttransplant patients currently alive in April 2006, including 43 (33%) on and 89 (67%) withdrawn from steroids. The percentages of patients who were on versus off steroids were compared for main causes of death. Thirty-eight percent of patients on steroids at the time of death died of graft vasculopathy compared with 46% of patients who had been weaned off steroids. Fifteen percent of deceased patients taking steroids at the time of death died of chronic rejection. DISCUSSION: The current literature focuses on early withdrawal or reduction of steroids or steroid avoidance after organ transplantation. Although steroid avoidance remains controversial, steroid withdrawal has been generally incorporated into immunosuppressive protocols. Early steroid withdrawal has a positive influence on the emergence of de novo osteoporosis and cataracts. The benefits of steroid avoidance versus withdrawal are controversial topics being currently debated.

Impact of direct electronic optometric referral with ocular imaging to a hospital eye service.

AIMS: A study to assess the feasibility, safety, and clinical effectiveness of electronic referral--with and without images--of patients directly from optometrists in primary care to the hospital eye service (HES) in contrast to the traditional paper-based referral, through the general practitioner (GP). METHODS: Three optometry practices sent consecutive referrals with images through the NHS Net to the HES. The standard General Ophthalmic Service form was electronically redesigned with additional information on patient choice for advice, appointment, or surgery. All paper referrals to the HES from the same three optometry practices before the study period were analysed (control group A) as were all paper referrals from the remaining optometrists in Fife (control group B). RESULTS: A total of 346 electronic referrals were received over 18 months. 218 (63%) were classified as requiring and 128 (37%) as not requiring a HES appointment. The latter were subsequently examined with unexpected pathology found in three cases (glaucoma, macular pigment epithelial detachment, and possible peripheral retinal tear). In both groups, the major pathologies reported were macular degeneration, cataract, glaucoma, diabetic retinopathy, and abnormal retinal appearances. A total of 17 (15%) patients in group A and 26 (8.4%) patients in group B were classified as not requiring HES appointment. These control groups indicate that approximately 10-15% of paper referrals are not seen in the HES. To summarise, therefore, 63% of people referred by the optometrist directly using electronic referral (with or without images) were given a HES appointment compared to 85% of people referred through the traditional paper method (without images) through their GP. CONCLUSION: Electronic referral with images to the HES is safe, speedy, efficient, and clinically accurate given some limitations and avoids unnecessary consultation in 37% of referrals.

Public health use of surveillance for West Nile virus in horses: Saskatchewan, 2003-2005.

West Nile virus (WNV) infection in horses was first reported in Canada in 2001 and in the province of Saskatchewan in 2002. This paper outlines the surveillance results of WNV in Saskatchewan horses from 2003 to 2005 and describes the usefulness of its inclusion in an integrated surveillance program in Saskatchewan. The number of human and horse cases was highest in 2003, the epidemic year and then substantially lower in 2004 and 2005. Horses provided additive information about WNV activity in rural areas with low human population, however, this required willingness and active participation by veterinarians and horse owners. Vaccination impedes the future use of horses in WNV surveillance for public health or veterinary purposes; however, for zoonoses where no vaccination is available, domestic animals would be useful components for surveillance. Integration of surveillance data from human and animal health provide the benefit of a more complex epidemiological picture that can be used to improve public health.

Treatment of superior vena cava obstruction secondary to pacemaker wires with balloon venoplasty and insertion of metallic stents.

AIMS: Pacemaker wires can result in stenosis of the superior vena cava and other central veins. The aim of this study is to demonstrate the safety and effectiveness of treating stenoses of the superior vena cava (SVC) and central veins with balloon venoplasty and metallic stent insertion in the presence of cardiac pacemaker wires. METHODS AND RESULTS: Three patients were referred to the department after developing symptomatic SVC obstruction following implantation of a cardiac pacemaker several years earlier. They were examined with duplex ultrasound and venography, which revealed significant stenoses of the central veins. These patients subsequently underwent endovascular treatment which involved balloon dilation and stent insertion. The treatment was successful in all three patients, without any complications. Long-term patency of up to 4 years is recorded. No pacemaker function dysfunction was encountered. CONCLUSION: SVC stenting is safe and effective in patients who develop the SVC obstruction after cardiac pacemaker insertion.

The Payment Error Prevention Program (PEPP): reducing Medicare payment errors in prospective payment system hospitals.

Peer Review Organizations (PROs) are charged by the Health Care Financing Administration (HCFA) to assist in protecting the integrity and solvency of the Medicare program. Recent audits of the Medicare program from the Office of Inspector General (OIG) revealed that more than $12 billion Medicare dollars in 1998 were spent in improper payments, with more than 25% attributed to prospective payment system (PPS) hospitals. The Payment Error Prevention Program (PEPP) is an initiative designed by HCFA in 1999 to assist PROs in meeting the goal of reducing payment errors in PPS hospitals. PEPP is implemented through the development of quality improvement (QI) methodologies. These projects are designed to achieve measurable improvements in processes and outcomes of payment errors. PEPP works to reduce payment errors at PPS hospitals through cooperative efforts with Ohio agencies and licensing boards, federal law enforcement organizations, HCFA contractors, hospital medical staffs, and medical and osteopathic associations.

Management of women with a family history of breast cancer.

Five to ten per cent of breast cancer results from an inherited germ line mutation. The main susceptibility genes are BRCA1 and BRCA2, but others include Cowden's disease, Li Fraumeni syndrome and ataxia-telangiectasia. For those with BRCA1 or BRCA2 mutations the lifetime probability of breast cancer is between 0.40 and 0.73. Genetic testing needs to be offered to young women with breast cancer before considering testing their relatives. The efficacy of surveillance in women with genetic susceptibility has yet to be proved. The value of tamoxifen as a preventive agent in women with genetic susceptibility has yet to be confirmed. Prophylactic bilateral mastectomy will probably reduce the risk of breast cancer but this may not be absolute because of the difficulty of removing all breast tissue. New approaches may enable the selective destruction of mammary epithelium without disturbance to breast architecture.

Long-term prospects for horses with grass sickness (dysautonomia).

Responses to questionnaires were received from 31 owners of horses or ponies treated for chronic grass sickness (dysautonomia). Contrary to previous opinions the respondents indicated that the majority of the animals were capable of strenuous work, had regained the weight they had lost and, apart from a few residual problems such as difficulty in coping with dry fibrous food, had returned to a normal life. They had recovered slowly and had involved the owners in considerable extra work, but all the owners indicated that they considered the effort to have been worthwhile.

Airway management training using the laryngeal mask airway: a comparison of two different training programmes.

Nurses without prior experience in the use of the laryngeal mask airway (LMA) were randomly allocated to one of two groups to be trained in the emergency technique of insertion of an LMA. Group A (32 nurses) were trained only on a manikin and group B (20 nurses) were trained on a manikin and with live anaesthetised patient practice in theatre (five successful insertions). Without further practice, both groups were asked to insert an LMA in a live patient in theatre 3 months after initial training. Three attempts per nurse were allowed. In group A, 75% passed the LMA successfully at the first attempt, 22% at the second attempt and 3% (one nurse) at the third attempt. In group B, 80% were successful at first attempt and 20% at the second attempt. Skill performance and retention were shown to be high following either training method, with no significant difference between the performance of either group (chi 2). We have shown that manikin-only training in the emergency technique for LMA insertion is as effective as live patient training. It is proposed that manikin training alone may be adopted as a future training modality if, as is expected, the use of the LMA in resuscitation becomes more commonplace.

Nisoldipine CC: clinical experience in ischaemic heart disease.

Nisoldipine coat core (CC) is a long-acting calcium channel blocker (CCB) with a slow and smooth onset of action. It is effective in the treatment of angina pectoris, increasing exercise duration, time to ST segment depression and time to onset of angina. The results of two studies reviewed here, in which patients received concomitant treatment with a beta-blocker, showed that the anti-anginal efficacy of nisoldipine CC, 40 mg once daily, measured at trough was comparable with amlodipine, 10 mg once daily, and with diltiazem retard, 120 mg twice daily, and that efficacy was maintained over a 24-hour period. The third trial reviewed here showed that nisoldipine CC was at least as effective as three-times-daily treatment with diltiazem (total dose 240 mg). To date, the effects of nisoldipine CC have been investigated in over 4,000 patients with hypertension and angina pectoris. Clinical experience suggests that once-daily nisoldipine CC is at least as well tolerated as other CCBs, provides consistent efficacy and is a useful treatment in the management of patients with angina pectoris. The CCBs show promising beneficial effects in experimental atherosclerosis and a small number of clinical trials show some effect on the progression of atherosclerosis in coronary artery disease and restenosis following coronary angioplasty. An ongoing long-term trial with nisoldipine CC after coronary angioplasty is discussed.

Evaluation of potential genotoxicity of pulsed electric and electromagnetic fields used for bone growth stimulation.

Medical devices emitting pulsed electric and electromagnetic fields have been found to be effective for a number of clinical applications including stimulation of bone and tissue growth. To determine whether pulsed fields of the type used in these clinical applications present a mutagenic hazard, electric and electromagnetic fields at two exposure levels were tested in the Ames test, CHO cell chromosomal aberration assay, BALB/3T3 cell transformation assay and unscheduled DNA synthesis assay in primary rat hepatocytes. For both field types, initial and independent repeat studies were performed for each assay at both clinical and supra clinical doses. In all assays, the results show a lack of cytotoxic, transforming and mutagenic activity. The data suggest that pulsed electric and electromagnetic fields of the type and dose levels used in bone growth stimulation lack mutagenic and transforming activity.

In vitro induction of micronuclei and chromosome aberrations by quinolones: possible mechanisms.

The bacterial gyrase inhibitors, ciprofloxacin and PD 124816, were tested for clastogenic and aneugenic activity in V79 Chinese hamster lung cells in vitro. Cells were exposed for 3 h, washed free of drug, and subcultured for assessment of various endpoints. For structural chromosomal aberration (SCA) analysis, cells were incubated for 18 h, and treated with Colcemid for 2 h before harvest. For micronucleus (MN) analysis, treated cells were incubated with cytochalasin B (CYB) for 16 h. Aneugenicity was assessed by utilizing antikinetochore antibody to detect kinetochore-containing (K +) MN. Both quinolones induced significant increases in SCAs and MN, indicating clastogenic activity. With both compounds, however, the MN response was apparent at lower doses, and remained much higher throughout the dose range than the SCA response. The induced MN were predominantly K --, indicating that aneugenicity was not playing a major role in their induction. A possible explanation for the chromosome effects is that cross-reactivity of the gyrase inhibitors with mammalian topoisomerase II interferes with the separation of chromatids at anaphase leading to chromosome breaks and MN. Quinolones are known to inhibit resolution of the normally transient topoisomerase II-DNA cleavable complex, which may result in chromosome stickness. Thus, SCAs detected in metaphase cells may be attributed to quinolone-induced inhibition of topoisomerase II prior to mitosis while MN arise in binucleated cells as a result of this effect which interferes with chromatid separation during anaphase.