Measuring the success of canine and feline preventative healthcare consultations: A systematic review.

Preventative healthcare consultations account for a large proportion of the veterinary caseload. This novel study is the first to methodically review all literature on canine and feline preventative healthcare consultations. Previous research has found these consultations to be different from health problem consultations in terms of communication style and content. Identifying relevant evidence and previously validated methods of measuring the success of these consultations will be useful when implementing strategies for optimisation. The aim of this study was to identify and assess the quality of existing literature which describes and/or measures the success of preventative healthcare consultations. Database searches of CAB Abstracts and Medline were conducted to identify published literature. Google searches were then conducted to identify any additional published or grey literature. Results were systematically screened to determine whether the returned sources were about cats and/or dogs, whether they related to preventative healthcare, and whether they described and/or measured the success of preventative healthcare consultations. For primary research citations which only described preventative healthcare consultations, data were extracted on the aspects of the consultations described. For citations which additionally measured the success of the consultations, the measures used, sampling technique, key results and key weaknesses were also extracted. Of 17,538 citations identified in total during the database searches, a total of seven relevant primary research citations were identified. All of these citations described aspects of the preventative healthcare consultation, such as consultation length, health problems discussed, actions taken and communication style. Only one primary research citation measured success of the consultation, using veterinarian satisfaction to determine success. In addition, 30 narrative citations, including expert opinion pieces, textbooks, guidelines without transparent methodology and conference presentations were identified. Google searches identified 224 relevant narrative citations, and five of the seven primary research citations identified by the database searches, but did not identify any additional relevant primary research citations. The results suggest that, despite accounting for around a third of all consultations, there is relatively little evidence describing preventative healthcare consultations and only one measure of success has been described for these consultations. This presents potential challenges when implementing strategies to optimise these consultations, as measures which are useful and relevant to veterinary practice should first be identified. Identifying useful measures of success will allow future strategies designed to maximise the benefits of these consultations to be meaningfully assessed for efficacy.

High and variable mortality of leatherback turtles reveal possible anthropogenic impacts.

The number of nesting leatherback turtles (Dermochelys coriacea) in the eastern Pacific Ocean has declined dramatically since the late 1980s. This decline has been attributed to egg poaching and interactions with fisheries. However, it is not clear how much of the decline should also be ascribed to variability in the physical characteristics of the ocean. We used data on individually marked turtles that nest at Playa Grande, Costa Rica, to address whether climatic variability affects survival and inter-breeding interval. Because some turtles might nest undetected, we used capture-recapture models to model survival probability accounting for a detection failure. In addition, as the probability of reproduction is constrained by past nesting events, we formulated a new parameterization to estimate inter-breeding intervals and contrast hypotheses on the role of climatic covariates on reproductive frequency. Average annual survival for the period 1993-2011 was low (0.78) and varied over time ranging from 0.49 to 0.99 with a negative temporal trend mainly due to the high mortality values registered after 2004. Survival probability was not associated with the Multivariate ENSO Index of the South Pacific Ocean (MEI) but this index explained 24% of the temporal variability in the reproductive frequency. The probability of a turtle to permanently leave after the first encounter was 26%. This high proportion of transients might be associated with a high mortality cost of the first reproduction or with a long-distance nesting dispersal after the first nesting season. Although current data do not allow separating these two hypotheses, low encounter rate at other locations and high investment in reproduction, supports the first hypothesis. The low and variable annual survival probability has largely contributed to the decline of this leatherback population. The lack of correlation between survival probability and the most important climatic driver of oceanic processes in the Pacific discards a climate-related decline and point to anthropogenic sources of mortality as the main causes responsible for the observed population decline.

Common decisions made and actions taken during small-animal consultations at eight first-opinion practices in the United Kingdom.

In order for veterinary surgeons to undertake an evidence-based approach to making decisions about their patients, it is important that new evidence is generated to support the clinical decision-making process. Many of the decisions are likely to be around the actions taken to treat or manage health problems discussed during the consultation, and little is currently known about the factors which affect the type of action taken. The aim of this study was to determine the decisions made and actions taken for health problems discussed during first-opinion small-animal consultations, as well as identifying factors which may affect the decision-making process. Data were gathered during direct observation of small-animal consultations conducted by 62 veterinary surgeons in eight first-opinion practices in the United Kingdom. For each patient presented, data were gathered on all health problems discussed during the consultation. The decision made (whether an action was taken or not) and the action taken where applicable (e.g. therapeutic treatment with antibiotics) was also recorded. A three-level multivariable logistic-regression model was developed, with problem (Level 1) nested within patient (Level 2) nested within consulting veterinary surgeon (Level 3), and a binary outcome variable of action versus no action. At least one action was taken for 69% (n=2203/3192) of all problems discussed. Therapeutic treatment was the most common action taken (n=1286/3192 problems; 40.3%), followed by management advice (n=1040/3192; 32.6%) and diagnostic work-up (n=323/3192; 10.1%). The most common therapeutic treatment was antibiotics (n=386/1286; 30%), while the most common management advice given was dietary advice (n=509/1040; 48.9%). The three explanatory variables remaining in the final model were whether the problem was a presenting or non-presenting problem, the type of diagnosis made, and the body system affected. Explanatory variables which did not remain in the final model were patient signalment, problem history, consultation type, clinical examination type, and who raised the problem (veterinary surgeon or owner). For over two-thirds of problems discussed, an action was taken which suggests these problems may be seen as important by the veterinary surgeon and/or pet owner. No action was taken for almost a third of cases which could represent 'watchful waiting', which has been highlighted as important in human healthcare. Future research should focus on the common actions taken, further exploring the complex decision-making process, and examining the effect of the decisions made on long-term patient outcomes.

Factors influencing common diagnoses made during first-opinion small-animal consultations in the United Kingdom.

It is currently unclear how frequently a diagnosis is made during small-animal consultations or how much of a role making a diagnosis plays in veterinary decision-making. Understanding more about the diagnostic process will help direct future research towards areas relevant to practicing veterinary surgeons. The aim of this study was to determine the frequency with which a diagnosis was made, classify the types of diagnosis made (and the factors influencing these) and determine which specific diagnoses were made for health problems discussed during small-animal consultations. Data were gathered during real-time direct observation of small-animal consultations in eight practices in the United Kingdom. Data collected included characteristics of the consultation (e.g. consultation type), patient (e.g. breed), and each problem discussed (e.g. new or pre-existing problem). Each problem discussed was classified into one of the following diagnosis types: definitive; working; presumed; open; previous. A three-level multivariable logistic-regression model was developed, with problem (Level 1) nested within patient (Level 2) nested within consulting veterinary surgeon (Level 3). Problems without a previous diagnosis, in cats and dogs only, were included in the model, which had a binary outcome variable of definitive diagnosis versus no definitive diagnosis. Data were recorded for 1901 animals presented, and data on diagnosis were gathered for 3192 health problems. Previous diagnoses were the most common diagnosis type (n=1116/3192; 35.0%), followed by open (n=868/3192; 27.2%) then definitive (n=660/3192; 20.7%). The variables remaining in the final model were patient age, problem history, consultation type, who raised the problem, and body system affected. New problems, problems in younger animals, and problems raised by the veterinary surgeon were more likely to result in a definitive diagnosis than pre-existing problems, problems in older animals, and problems raised by the owner. The most common diagnoses made were overweight/obese and periodontal disease (both n=210; 6.6%). Definitive diagnoses are rarely made during small-animal consultations, with much of the veterinary caseload involving management of ongoing problems or making decisions around new problems prior to a diagnosis being made. This needs to be taken into account when considering future research priorities, and it may be necessary to conduct research focused on the approach to common clinical presentations, rather than purely on the common diagnoses made. Examining how making a diagnosis affects the actions taken during the consultation may shed further light on the role of diagnosis in the clinical decision-making process.

Investigating preventive-medicine consultations in first-opinion small-animal practice in the United Kingdom using direct observation.

Preventive-medicine consultations account for a large proportion of the veterinary caseload and previous research has suggested these consultations are fundamentally different from those in which the animal is presented for a specific health problem. There has been recent controversy around some aspects of preventive medicine for cats and dogs, and the full health benefits of the preventive-medicine consultation remain unclear. The aim of this study was to compare characteristics of the consultation and the problems discussed during the consultation between preventive-medicine consultations and other types of consultations. Data were gathered during direct observation of small-animal consultations in seven first-opinion practices in the United Kingdom. Data collected included type of clinical examination performed, patient signalment, and details of all problems discussed (including whether the problem was presenting or non-presenting, new or pre-existing, who had raised the problem, body system affected and whether an action was taken). A two-level multivariable logistic-regression model was developed, with canine and feline patients at Level 1 nested within consulting veterinary surgeons at Level 2, and a binary outcome variable of preventive-medicine consultation versus specific health-problem consultation. A total of 1807 patients were presented, of which 690 (38.2%) presented for a preventive-medicine consultation. Dogs were the most frequently presented species (n=1168; 64.6%) followed by cats (n=510; 28.2%), rabbits (n=86; 4.8%) and patients of other species (n=43; 2.4%). The five variables remaining in the multi-level model were whether multiple patients were presented, patient age, clinical examination type, weighing and number of problems discussed. Species, breed, sex, neutering status and practice did not remain in the final model. Many non-presenting problems, including both preventive-medicine problems and specific-health problems, were discussed and acted upon during all types of consultations. Dental and behavioural non-presenting problems were discussed more frequently during preventive-medicine consultations compared with specific health-problem consultations. Preventive-medicine consultations represent an opportunity for veterinary surgeons to discuss other aspects of preventive medicine, and to detect and manage new and ongoing health problems. A greater evidence base is needed to understand whether detecting and managing underlying disease during the preventive-medicine consultation has a positive impact on lifelong patient health and welfare.

Investigating common clinical presentations in first opinion small animal consultations using direct observation.

Understanding more about the clinical presentations encountered in veterinary practice is vital in directing research towards areas relevant to practitioners. The aim of this study was to describe all problems discussed during a convenience sample of consultations using a direct observation method. A data collection tool was used to gather data by direct observation during small animal consultations at eight sentinel practices. Data were recorded for all presenting and non-presenting specific health problems discussed. A total of 1901 patients were presented with 3206 specific health problems discussed. Clinical presentation varied widely between species and between presenting and non-presenting problems. Skin lump, vomiting and inappetence were the most common clinical signs reported by the owner while overweight/obese, dental tartar and skin lump were the most common clinical examination findings. Skin was the most frequently affected body system overall followed by non-specific problems then the gastrointestinal system. Consultations are complex, with a diverse range of different clinical presentations seen. Considering the presenting problem only may give an inaccurate view of the veterinary caseload, as some common problems are rarely the reason for presentation. Understanding the common diagnoses made is the next step and will help to further focus questions for future research.

Capturing the complexity of first opinion small animal consultations using direct observation.

Various different methods are currently being used to capture data from small animal consultations. The aim of this study was to develop a tool to record detailed data from consultations by direct observation. A second aim was to investigate the complexity of the consultation by examining the number of problems discussed per patient. A data collection tool was developed and used during direct observation of small animal consultations in eight practices. Data were recorded on consultation type, patient signalment and number of problems discussed. During 16 weeks of data collection, 1901 patients were presented. Up to eight problems were discussed for some patients; more problems were discussed during preventive medicine consultations than during first consultations (P<0.001) or revisits (P<0.001). Fewer problems were discussed for rabbits than cats (P<0.001) or dogs (P<0.001). Age was positively correlated with discussion of specific health problems and negatively correlated with discussion of preventive medicine. Consultations are complex with multiple problems frequently discussed, suggesting comorbidity may be common. Future research utilising practice data should consider how much of this complexity needs to be captured, and use appropriate methods accordingly. The findings here have implications for directing research and education as well as application in veterinary practice.

Survey of the UK veterinary profession: common species and conditions nominated by veterinarians in practice.

The practice of evidence-based veterinary medicine involves the utilisation of scientific evidence for clinical decision making. To enable this, research topics pertinent to clinical practice need to be identified, and veterinary clinicians are best placed to do this. The main aim of this study was to describe the veterinary population, the common species and conditions veterinary clinicians nominated they saw in practice and how much information clinicians perceived was available in the literature for these. A questionnaire was distributed to all Royal College of Veterinary Surgeons registered veterinarians agreeing to be contacted for research purposes (n=14,532). A useable response rate of 33 per cent (4842/14,532) was achieved. The most commonly seen species reported by vets were dogs, cats and rabbits followed by equines and cattle. Overall, skin conditions were most commonly mentioned for small animals, musculoskeletal conditions for equines and reproduction conditions for production animals. Veterinary clinicians perceived there was a higher level of information available in the literature for conditions in dogs, cattle and equines and lower levels for rabbits and guinea pigs. The results from this study can be used to help define the research needs of the profession to aid the incorporation of evidence in veterinary practice.

Excess risk of hip fractures attributable to the use of antidepressants in five European countries and the USA.

SUMMARY: The association between antidepressant use and hip fracture remains unclear. We conducted a systematic review to estimate Population Attributable Risks (PAR) for France, Germany, Italy, Spain, UK, and the USA. We report a heterogeneous prevalence of antidepressant use and related PARs, both lowest for Italy and highest for the USA. INTRODUCTION: Antidepressant use has been associated with an increased hip fracture risk in observational studies. However, the potential contribution of antidepressant consumption on the population rate of hip fractures has not been described. Our aim was to estimate the impact of the use of different classes of antidepressants on the rate of hip fracture at a population-level in France, Germany, Italy, Spain, the UK, and the USA. METHODS: We conducted a systematic literature review to estimate the pooled relative risk (RR) of hip fracture according to use of antidepressants. Prevalence rates of antidepressant use (Pe) in 2009 were calculated for each country using the The Intercontinental Medical Statistics database and three public databases from Denmark, the Netherlands, and Norway. Both the RR and Pe were used to calculate PAR of hip fractures associated with antidepressant use. RESULTS: The literature review showed an increased risk of hip fractures in antidepressant users (RR, 1.7; 95 % confidence interval (CI), 1.5-2.0). Rates of antidepressant use showed considerable differences between countries, ranging from 4.4 % (Italy) to 11.2 % (USA) in the year 2009. The estimated PAR of antidepressants on hip fracture rates were 3.0 % (95 % CI, 2.0-4.1; Italy), 3.1 % (95 % CI, 2.1-4.3; Germany), 3.8 % (95 % CI, 2.6-5.3; France), 4.8 % (95 % CI, 3.3-6.5; Spain), 4.9 % (95 % CI, 3.4-6.8; UK), and 7.2 % (95 % CI, 5.0-9.9; USA). PARs differed for different types of antidepressants, with highest attributable risks for selective serotonin reuptake inhibitors. CONCLUSIONS: These findings suggest that the potential contribution of antidepressant use to the population rate of hip fractures in the five large EU countries and the USA varies between 3 and 7 %.

Potential impact of benzodiazepine use on the rate of hip fractures in five large European countries and the United States.

Benzodiazepine use increases the risk of falls and has been associated with an increased risk of hip fractures. Our aim was to estimate the possible population impact of the use of benzodiazepines on the rate of hip fracture in France, Germany, Italy, Spain, the United Kingdom, and the United States. We conducted a literature review to estimate the pooled relative risk (RR) for hip fractures and use of benzodiazepines. Prevalence rates of benzodiazepine use in 2009 were calculated for each country using the IMS MIDAS database and three public databases in Denmark, the Netherlands, and Norway. Both the RR and prevalence rates were used for calculation of population attributable risks (PARs) of hip fractures associated with benzodiazepine use. The literature review showed an increased risk of hip fractures in benzodiazepine users (RR = 1.4, 95 % CI 1.2-1.6). Rate of benzodiazepine use showed considerable differences between countries, ranging from 4.7 % to 22.3 % of population ever in a 1-year period. These are reflected in results for the PARs; estimated attributions of benzodiazepines to the rate of hip fractures were 1.8 %, 95 % CI 1.1-2.6 (Germany); 2.0 %, 95 % CI 1.2-2.8 (United Kingdom); 5.2 %, 95 % CI 3.2-7.3 (Italy); 7.4 %, 95 % CI 4.5-10.0 (France); 8.0 %, 95 % CI 4.9-11.0 (United States); and 8.2 %, 95 % CI 5.1-12.0 (Spain). PAR estimates suggest that the potential attribution of benzodiazepine use on the population rate of hip fractures in the five specified European countries and the United States varies between 1.8 % and 8.2 %. During the next phase of the IMI-PROTECT study, a comparison with individual patient data will show whether this approach is valid.

Comorbidities of idiopathic thrombocytopenic purpura: a population-based study.

A person experiencing more than one medical condition may have ambiguous clinical presentation. ITP is a serious autoimmune disease with little epidemiological evidence on its burden, risk factors, and comorbidities. Using the United Kingdom general practice research database, we conducted a 14 years population-based case control-type study to explore medical conditions more likely to cooccur with ITP and their temporal relationship in association with ITP. ITP patients were matched to non-ITP on practice, age, gender, and follow-up period. Potential comorbidities were represented by patients' medical information at the preferred term level of the MedDRA international classification. As well as death (OR = 60.0; 95% CI [4.47-806.0]) and known clinical signs and symptoms of ITP, ITP is associated with considerable number of medical conditions. The association between ITP and some of these conditions is apparent both before and after ITP diagnosis. Specific targeted studies can now be setup to reexamine observed associations.

A randomised placebo-controlled trial to explore the effect of suppressive therapy with acyclovir on genital shedding of HIV-1 and herpes simplex virus type 2 among Zimbabwean sex workers.

OBJECTIVES: To determine the effect of daily acyclovir on genital shedding of HIV-1 and herpes simplex virus type 2 (HSV-2) in a randomised placebo-controlled trial among rural Zimbabwean sex workers. METHODS: 214 women were recruited and tested for HIV-1 and HSV-2 antibodies, HIV plasma viral load, CD4 lymphocyte count and genital swabs for qualitative detection of HIV-1 and HSV-2 genital shedding. Women were randomly assigned to acyclovir 400 mg twice a day for 12 weeks or matching placebo and were followed weekly to detect HIV-1 or HSV-2 genital shedding. Shedding analyses were only undertaken on 125 women co-infected with HSV-2 and HIV-1. Data were analysed using logistic regression, with random effects modelling used to account for repeated measurements on the same women. RESULTS: All women were randomly assigned to acyclovir or placebo; 125 of whom were co-infected with HIV-1 and HSV-2. 69 women were randomly assigned to acyclovir and 56 to placebo. Although twice daily acyclovir reduced rates of HSV-2 genital shedding, (adjusted odds ratio (AOR) 0.24; 95% CI 0.12 to 0.48; less than p<0.001), it had no effect on the proportion of visits at which HIV-1 shedding was detected (AOR 1.08; 95% CI 0.48 to 2.42; p = 0.9). Adherence varied between participants but even when adherence was high (as determined by pill count and extent of HSV-2 suppression) HIV-1 shedding was not reduced. CONCLUSION: Among these HIV-1 and HSV-2-seropositive women, suppressive acyclovir therapy had no effect on the rate of HIV genital shedding despite a reduction in genital HSV-2. Treatment adherence and its measurement clearly affect the interpretation of these results.

Sexual behaviour and condom use among individuals with a history of symptomatic genital herpes.

OBJECTIVES: This study describes the differences in sexual behaviour in individuals with genital herpes (GH) during "symptomatic" and "asymptomatic" periods of the disease. METHODS: A cross sectional questionnaire was undertaken by 1193 individuals attending clinics between 1998 and 2001. All participants in this analysis were in heterosexual, monogamous partnerships, self identified with a history of symptomatic GH and with confirmed HSV-2 infection. RESULTS: Sexual activity reported during asymptomatic v symptomatic periods of GH was 98% v 40% (p<0.001), 76% v 29% (p<0.001), and 25% v 11% (p<0.001) for vaginal, oral, and anal intercourse, respectively, while "always" condom use during asymptomatic and symptomatic periods was 20% v 35% (p<0.001), 2% v 7% (p<0.001), and 10% v 15% (p = 0.131), respectively. The proportion of individuals who either abstained from vaginal intercourse or "always" used condoms was 21% v 74% (p<0.001), for asymptomatic v symptomatic periods. Multivariable analyses indicated that factors associated with engaging in intercourse during symptomatic periods of GH included current intrauterine device use (adjusted odds ratio (aOR) = 2.96, 95% confidence interval (CI) = 1.46 to 6.02); living in Latin America (aOR = 2.16, CI = 1.19 to 3.91) or Europe (aOR = 1.67, CI = 1.21 to 2.28), compared with North America; previous sexually transmitted disease (aOR = 1.42, CI = 1.08 to 1.89); a higher number of sexual acts per month (aOR = 1.09, CI = 1.06 to 1.11); and a higher number of GH recurrences per year (aOR = 1.08, CI = 1.03 to 1.12). CONCLUSIONS: These data indicate that the majority of people with GH either abstained from intercourse or "always" used condoms during symptomatic periods of GH. However, condom use was relatively low during asymptomatic periods in comparison with symptomatic periods. These results highlight that further education on GH prevention is warranted, particularly for symptomatic periods.

Adolescent sexuality and the HIV epidemic in Yaoundé, Cameroon.

Adolescents are the focus of many interventions that aim to prevent HIV transmission. In order for these interventions to be effective, it is essential to understand adolescents' sexual behaviour. Using data collected in Yaoundé, Cameroon, in 1997, the study analysed risk exposure and HIV prevalence among 426 men and 510 women aged 15-24. Although risky behaviours seem to be more prevalent among young men, their HIV prevalence remains under 1%. In contrast, HIV prevalence is high among young women (7.5%), even those who report having had few sexual partners. Mixing patterns among sexual partners, and especially the age difference between men and women, do not seem to be sufficient to explain the large male-female discrepancy in HIV prevalence that is evident in these data. The results are therefore probably due to a greater susceptibility to infection of young women than men. This study highlights the necessity of reinforcing prevention campaigns among youth and fighting the obstacles that continue to impede the use of condoms in this population.

Performance of focus ELISA tests for herpes simplex virus type 1 (HSV-1) and HSV-2 antibodies among women in ten diverse geographical locations.

To determine the sensitivity and specificity of Focus HerpeSelect ELISAs, sera or plasma samples from women aged 18-55 years were collected in ten cities from eight countries and tested by HerpeSelect HSV-1 ELISA (Focus-HSV-1) and by HerpeSelect HSV-2 ELISA (Focus-HSV-2). Sera with Focus-HSV-2-positive results were retested; 94% of the 3617 samples retested were positive. A subset of sera from each site was then selected, based on the HSV-2 results, and tested by Western blot (WB). The sensitivity and specificity were determined with samples from ten sites (n = 967) for Focus-HSV-1 and from seven sites (n = 675) for Focus-HSV-2. Focus-HSV-1 and WB results were concordant (both negative or both positive) for 97% of samples, with 99% sensitivity and 77% specificity. Specimens from Songkla, Thailand had 84% concordance with WB results for HSV-1, while three other sites had 100% concordance. Concordance of Focus-HSV-2 and WB was 92%, with 97% sensitivity and 89% specificity. Ibadan, Nigeria had 78% concordance. Focus-HSV-2 sensitivity and specificity in sites other than Ibadan were 97% and 93%, respectively. Raising the positive cut-off index value for HSV-2 from 1.1 to 3.5 yielded a sensitivity of 90% and a specificity of 96%. A sensitivity of 90% and a specificity of 98% were achieved for sites other than Nigeria with the higher cut-off. In summary, the sensitivity and specificity of the Focus-HSV-1 and Focus-HSV-2 tests varied by site. Performance data generated in one area may not be applicable to other populations.