Microfilaremic infection in canine filariosis in Colombia: a challenge in morphological and molecular diagnostics.

Canine filariosis is caused by filiform nematodes and affects several species of animals as well as humans. The disease produces a wide range of symptoms that can often be confused with other diseases, which increases the complexity of its diagnosis. The search for methodologies to facilitate its diagnosis is a challenge, and specific and differential identification of the parasite species causing the disease holds key to a successful diagnosis. In Colombia, there is a problem of underdiagnosis of filariosis in microfilaremic dogs infected by Dirofilaria immitis and Acanthocheilonema reconditum, and of microfilaremias not related to heartworm disease. The highest prevalences have been reported for D. immitis infections, although new cases of A. reconditum infections are beginning to appear. The aim of this study was to differentiate the microfilariae infections caused by D. immitis and A. reconditum by a morphological and molecular characterization of microfilariae so as to facilitate an accurate diagnosis of canine filariosis in the metropolitan area of Bucaramanga (Colombia). For this purpose, 400 blood samples with anticoagulants were collected from the dogs and analyzed with the help of a commercial immunochromatography kit for the detection of D. immitis circulating antigen. The Woo, Knott, and polymerase chain reaction (PCR) techniques were employed for determining the parasite count, morphological observation, and molecular identification of microfilariae present in the dogs respectively. The prevalence of microfilaremic dogs in Bucaramanga metropolitan area was 18.75% (75/400). The prevalence of dogs that tested positive for D. immitis in the antigen and in PCR tests was 1.25% (5/400) and 1% (4/400), respectively. Furthermore, the PCR test revealed that 17.75% of the microfilaremic dogs tested positive for A. reconditum (71/400) (first report in the metropolitan area of Bucaramanga), with one animal co-infected by both species, and 0% for D. repens (0/400). However, by morphological characterization, 4% of the microfilariae (3/75) corresponded to D. immitis, 20% (15/75) to D. repens, and 76% (57/75) to A. reconditum. The use of molecular diagnostic methods such as PCR aids in the specific identification of the parasite, thus making it a more accurate method than the morphological characterization of microfilariae. The identification of the parasites by PCR helps improve the veterinary diagnosis of canine filariosis in Colombia, which would lead to the establishment of an appropriate treatment protocol for each species of filaria and also to the generation of reliable data to be used at the clinical and epidemiological levels.

Atypical case of subcutaneous filariosis in a cat caused by Dirofilaria immitis.

Subcutaneous dirofilariosis is a well-known disease caused mainly by Dirofilaria repens and described in several mammalian species including humans, dogs, and cats. Additionally, early developing stages of the heartworm Dirofilaria immitis are rarely reported in subcutaneous localization from humans and dogs. To our knowledge, confirmed clinical evidence of this condition has not been described in the cats yet, even if the feline hosts can be affected either by the classic adult-related heartworm form or heartworm-associated respiratory disease (HARD) caused by immature stages. A 2 year old, spayed male cat was presented for three subcutaneous nodules on the head and trunk. The cat lived in Northern Italy and was regularly vaccinated and treated monthly with an antiparasitic spot on formulation containing selamectin. One of the three nodules was surgically excised and examined. Histology showed the presence of a nodular lesion in the subcutis characterized by a severe inflammatory infiltrate composed of macrophages, small lymphocytes, with fewer eosinophils, and mast cells, supported by a proliferation of mature fibroblasts (fibrosis). Inflammatory cells were multifocally surrounding sections of parasites identified as adult nematodes. Microscopic features were compatible with D. immitis, which has been molecularly confirmed (98.2% identity to D. immitis isolate OP107739). The cat tested negative for D. immitis antigenemia and the two remaining nodules disappeared spontaneously in a few months. In region where heartworm is prevalent, aberrant localization of D. immitis should be considered in the differential diagnoses of subcutaneous filarial worms in cats and dogs.

Motile microfilaria captured by fluorescent microscopy and the unmasking of eosinophilia following treatment.

A 24-year-old patient from Cameroon presented to our hospital because of a foreign structure in her left eye. To our knowledge, for the first time, fluorescent microscopy revealed motile microfilariae, and the diagnosis of loiasis was established. Despite substantial microfilaremia, eosinophilia only unmasked after the initiation of antiparasitic therapy.

New distribution patterns of Dirofilaria immitis in Italy.

In recent decades, the number of autochthonous cases and foci of Dirofilaria immitis in dogs from southern regions has increased considerably, suggesting that the distribution of the species is not limited to northern Italian regions. This epidemiological picture emerges from case reports or studies in specific locations where outbreaks of heartworm disease have occasionally been reported together with the presence of mosquito vectors. To obtain a more comprehensive picture of the current distribution of D. immitis in southern Italy, a multicenter cross-sectional survey of canine filariasis was conducted. Owned and sheltered dogs (n = 1,987) were included in the survey regardless their breed, attitude and/or sex. All included dogs were older than 1 year and had no history of chemoprophylactic treatment against filarioses. A blood sample was collected from enrolled dogs and screened by modified Knott's test and, when positive, tested using D. immitis specific ELISA rapid test (SNAP 4DX, IDEXX). The overall microfilaremia prevalence was 17% (n = 338) being single-species infection (92.6%) more common that mixed (7.4%). Remarkably, D. immitis was the most frequent species detected with an overall prevalence of 11.4% (n = 227), followed by Dirofilaria repens (n = 74; 3.7%), and Acanthocheilonema reconditum (n = 12; 0.6%). Sheltered dogs were significantly more infected by D. immitis, as well as mongrel dogs and animals housed in rural areas. Data here reported indicate that D. immitis is largely present in southern Italy, raising awareness about the necessity of proper screening and chemoprophylactic treatments in exposed animals.

Parasitism of Dirofilaria incrassata Molin, 1858 in coatis (Nasua nasua).

Populations of the coati, Nasua nasua, like the populations of other wild animals, are regulated by several biotic or abiotic factors. For example, parasites act as a biotic factor affecting the dynamics and density of coati populations. The parasitic nematodes of coatis include Dirofilaria species, such as Dirofilaria immitis, Dirofilaria repens, and Dirofilaria incrassata. Considering that there are few records on parasitism by D. incrassata, including information on the life cycle or location in the host body, this study aimed to investigate the infection of N. nasua by D. incrassata in midwestern Brazil. Thus, two coatis (males and adults) from the Cerrado of Goiás, which died (cause unknown) at the Wild Animal Screening Center/IBAMA in the municipality of Goiânia, Goiás, Midwestern of Brazil, were dissected and all helminths found were collected, identified following specific keys and quantified. A total of 85 specimens of D. incrassata were collected, with a mean parasitic intensity of 42.5 and a parasitic amplitude ranging from 40 to 45, measuring 41-93 mm in length and 0.23-0.45 mm in width. All helminths were adults and were distributed in the superficial and deep fascia (at different levels) from the neck to the hind limb. Most helminths were tangled, with some encased in a connective tissue film. Most reported human heartworm cases refer to subcutaneous or ocular heartworm infection, mainly caused by D. repens, although other species of heartworm may be associated. D. incrassata was not reported as zoonotic agent, diferently of other Dirofilaria species associated with wild animals and with zoonotic potential in the Americas. This study reiterates N. nasua as the definitive host for D. incrassata and the subcutaneous tissue as the site of choice for this helminth in the adult form. In addition, it reports new body regions where the parasite occurs. This study is the first to document the occurrence of D. incrassata infestation in the State of Goiás, Brazil.

Emergent and Neglected Equine Filariosis in Egypt: Species Diversity and Host Immune Response.

Equine filariosis (EF) is a neglected vector-borne disease caused by nematode species belonging to the Onchocercidae and Setariidae families. Aside from their zoonotic potential, some species are responsible for serious health problems in equids worldwide, leading to significant economic difficulties. Here, we molecularly investigated equine blood samples (320 horses and 109 donkeys from Egypt) and four adult worms isolated from the peritoneal cavity of 5 out of the 94 slaughtered donkeys. In addition, quantitative enzyme-linked immunoassays (ELISAs) targeting circulating cytokines were used to identify whether the immunological profile of the infected animals is a Th1 (i.e., INF-gamma as indicator) or Th2 (i.e., IL-5 and IL-10 as indicators) response type. Overall, 13.8% and 0.3% of the donkeys and horses, respectively, were scored as positive for filaroid DNA. The 18S phylogeny revealed the occurrence of three different filaroid species, identified here as Mansonella (Tetrapetalonema) sp., Setaria digitata and Dirofilaria repens. Th1 (INF-gamma and IL-5) and Th2 (IL-10) immune response types were identified in equines infected with S. digitata and Mansonella (T.) sp., respectively. These results provide new data on the species diversity of EF in Egypt and extend knowledge of the downregulation of the protective immune response by the potentially zoonotic Mansonella (T) sp. There is an urgent need to implement control measures to preserve equine health and limit the propagation of these vector-borne filaroids in Egypt.

Probe-based qPCR as an alternative to modified Knott's test when screening dogs for heartworm (Dirofilaria immitis) infection in combination with antigen detection tests.

BACKGROUND: Current recommendations for diagnosis of Dirofilaria immitis infection in dogs rely on the detection of antigen produced largely by adult females coupled with the visualization of microfilariae (mf) in the circulation via a microfilaria detection test (MFDT). It is hypothesized that qPCR assays used in parallel with antigen detection tests will perform better in detecting mf than modified Knott's test (MK), when combined with antigen detection. This study compares probe-based qPCR and MK techniques for mf detection used in parallel with the DiroCHEK® antigen test to screen for heartworm infection in shelter dogs. METHODS: Matching blood and serum samples were collected from 300 shelter dogs in Brazos and Harris counties, Texas, USA. Blood was assessed for the presence of mf via MK and the presence of D. immitis DNA by a species-specific probe-based qPCR assay. Serum samples were tested for the presence of heartworm antigen using DiroCHEK® before and after immune complex dissociation (ICD) via heat treatment. In addition, the performance of each diagnostic test was evaluated via Chi-square test, Cochran's Q test, and post hoc analysis. RESULTS: Qualitatively, MK detected mf in 22.0% (66/300) of samples, 55 of which were morphologically identified as D. immitis and 11 as Acanthocheilonema reconditum. The range of heartworm mf was 28 to 88,803 mf/ml (median: 6627.5). Real-time PCR detected D. immitis DNA in 20.7% (62/300) of samples. Heartworm antigen was detected in 24.7% (74/300) of samples pre-ICD, and in 29.3% (88/300) post-ICD. When comparing tests, the Chi-square and McNemar's tests showed that the difference between positive and negative proportions was statistically significant. The Cochran test showed the difference in the distributions of cases and non-cases was significant when individual tests were combined (χ2 = 62.3, df = 3, P < 0.0001) and when parallel methods were combined (χ2 = 43.1, df = 4, P < 0.0001). CONCLUSION: Considering individual and combined test performances, practicality, and efficient use of bench time, this heartworm-specific probe-based qPCR method is a viable option as a mf detection test to be used in parallel with antigen tests for canine heartworm infection in diagnostic and research settings.

Molecular characterization of Dipetalonema yatesi from the black-faced spider monkey (Ateles chamek) with phylogenetic inference of relationships among Dipetalonema of Neotropical primates.

Species of the genus Dipetalonema are parasitic nematodes of the family Onchocercidae (Nematoda; Filarioidea) which infect the peritoneal cavity of Neotropical primates. Of these, six species have been taxonomically described, two of these have been reported infecting the black-faced spider monkey (Ateles chamek): Dipetalonema gracile and Dipetalonema yatesi. Description of Dipetalonema species have been based on morphological characteristics, and their phylogenetic relationships remain unresolved. A few molecular studies have been carried out in Dipetalonema spp. infecting Neotropical primates. Seven filarioid nematodes (6 females and one male) recovered from one A. chamek in the Peruvian Amazon rainforest were morphologically identified as D. yatesi and molecularly characterized. A multi-locus genetic analysis of nuclear ribosomal region (18S) and mitochondrial (cox1, 12S, and nad5) gene sequences supported D. yatesi as a distinct lineage and yielded a highly resolved phylogenetic lineage tree for this filarioid genus of Neotropical primates. Our results highlighted that Dipetalonema species are divided in two well-supported clades, one containing D. yatesi and D. caudispina, and the second containing D. robini, D. gracile, and D. graciliformis. Due to sequence ambiguities from GenBank entries, relationships among isolates of D. gracile and D. graciliformis cannot be fully resolved, which requires further investigation. However, this suggests that these could represent a species complex. Our study confirms that D. yatesi is a valid species and constitutes the first molecular phylogenetic analysis of this parasite in black-faced spider monkeys.

Integration of Microscopic, Serologic and Molecular Techniques for Detection of Filarial Parasites in Dogs in Malaysia.

PURPOSE: Canine filariosis in domestic dogs caused by several species of filarids is an emerging vector-borne disease and the spread of this disease remains a global veterinary and public health concern. However, information regarding these filarids and their epidemiological patterns remains scarce in Malaysia. The present study aimed to determine the infection rate and associated risk factors of filarial parasites in dogs in Malaysia. METHODS: A total of 399 dog blood samples were collected from veterinary hospitals and animal shelters in Malaysia to determine the infection rate and associated risk factors via a combination of microscopic, serologic and molecular diagnostic techniques. RESULTS: Two species of canine filariae identified in this study were Dirofilaria immitis (6.5%) and Brugia pahangi (1.3%), and their infections were associated with cross breed, medium size and short hair (p < 0.05). CONCLUSIONS: A new pair of primers was developed to complement the recovery of the 12S rRNA gene fragment of filarial parasites. This study represents the first molecular evidence of B. pahangi in dogs in Malaysia.

A rare clinical presentation of human Dirofilaria repens infection as a pseudo-tumour of the epididymis - Case Report.

Introduction. Epididymal dirofilariasis is one of the unusual manifestations of this zoonosis. In Slovakia, this is the third case out of 20 Dirofilaria repens infected patients in whom the worm (the parasite) was identified in the epididymis. The patient felt a painless tumour about 2 cm in size on the left testicle. During ultrasound examination, the radiologist observed a cyst containing a live worm within the epididymis. After mechanical stimulation, the movement characteristic for filarial worms (´filarial dance sign´) appeared. An orchiectomy was performed at the Department of Urology in the University Hospital in Kosice. Histopathology confirmed a parasitic cyst with a worm, and based on characteristic morphological features, the parasite was identified as Dirofilaria repens. Objective. The aim of case report is to alert physicians to the possibility dirofilarial infection of the epididymis, where tumors and cystic structures often occur and to present clinical signs of the disease.

[Parasitic dermatoses from abroad]. / Parasitäre Reisedermatosen.

Increased migration, the omnipresent desire to travel, climate change and a globally more mobile population enhance the risk of spreading infectious, tropical pathogens across international borders. In addition to diarrhea and fever, skin diseases present one of the most common reasons for a medical consultation upon return among travelers. These diseases are often caused by parasites. Detailed data on infectious travel diseases is scarce. However, demographic, endemic and travel-related information represent the basic requirements for physicians to choose appropriate diagnostics and adequate treatment for affected patients. This article gives an overview of common parasitic travel dermatoses, their specific diagnostic workup, treatment and preventive measures.

Scanning Electron Microscopy Observations of Loa loa (Nematoda).

We present a case report of periocular Loa loa. The key feature of L. loa distinguishing it from other human filarial parasites are cuticular bosses, which are presented in images from a light microscope and a scanning electron microscope. The cuticular bosses could be divided into three subtypes not previously described.

Development of a multiplex qPCR-based approach for the diagnosis of Dirofilaria immitis, D. repens and Acanthocheilonema reconditum.

BACKGROUND: Dirofilaria immitis, D. repens and Acanthocheilonema reconditum are the main causative agents of zoonotic canine filariosis. METHODS: We developed a combined multiplex approach for filaria and Wolbachia detection using the 28S-based pan-filarial and 16S-based pan-Wolbachia qPCRs, respectively, involving a fast typing method of positive samples using triplex qPCR targeting A. reconditum, D. immitis and D. repens, and a duplex qPCR targeting Wolbachia of D. immitis and D. repens. The approach was complemented by a duplex qPCR for the differential diagnosis of heartworms (D. immitis and Angiostrongylus vasorum) and pan-filarial cox1 and pan-Wolbachia ftsZ PCRs to identify other filarial parasites and their Wolbachia, respectively. A total of 168 canine blood and sera samples were used to validate the approach. Spearman's correlation was used to assess the association between filarial species and the strain of Wolbachia. Positive samples for both the heartworm antigen-test after heating sera and at least one DNA-positive for D. immitis and its Wolbachia were considered true positive for heartworm infection. Indeed, the presence of D. repens DNA or that of its Wolbachia as well as A. reconditum DNA indicates true positive infections. RESULTS: The detection limit for Wolbachia and filariae qPCRs ranged from 5 × 10-1 to 1.5 × 10-4 mf/ml of blood. When tested on clinical samples, 29.2% (49/168) tested positive for filariae or Wolbachia DNA. Filarial species and Wolbachia genotypes were identified by the combined multiplex approach from all positive samples. Each species of Dirofilaria was significantly associated with a specific genotype of Wolbachia. Compared to the true positives, the approach showed excellent agreement (k = 0.98-1). Unlike D. immitis DNA, no A. vasorum DNA was detected by the duplex qPCR. The immunochromatographic test for heartworm antigen showed a substantial (k = 0.6) and a weak (k = 0.15) agreements before and after thermal pre-treatment of sera, respectively. CONCLUSIONS: The proposed approach is a reliable tool for the exploration and diagnosis of occult and non-occult canine filariosis. The current diagnosis of heartworm disease based on antigen detection should always be confirmed by qPCR essays. Sera heat pre-treatment is not effective and strongly discouraged.

New promising method to assess microfilarial Loa loa load on the peripheral blood.

Loiasis is a vector-borne parasitic disease caused by the filarial Loa loa (L. loa). Definitive diagnosis can be done by identifying and counting microfilariae in the peripheral blood by microscopy and with L.loa-specific PCR. An additional diagnostic method is the detection of L.loa-specific antibodies. Accurate methods are needed to automate quantification of microfilaria (mf) in peripheral blood. Indeed, the treatment procedure depends on the microfilarial L. loa load in blood. We report the first documented use of flow cytometry as a new method to count microfilaraemia in peripheral blood from a patient with L. loa infection. The diagnosis of loiasis was strongly suspected based on clinical presentation and rapidly confirmed by identifying typical features of L. loa in the peripheral blood. This diagnosis was achieved by flow cytometry using a specific fluorescence pattern for microfilaraemia count. The current report highlights the potential of flow cytometry to assess microfilarial L. loa load from a patient with loiasis infection.

New findings of Setaria tundra and Setaria cervi in the red deer (Cervus elaphus) in Poland.

Our study aimed at examining the phylogenetic position of the newly-found Setaria nematodes obtained from the red deer (Cervus elaphus) based on sequences of the mitochondrial cytochrome c oxidase subunit 1 (COX-1). Alignment and phylogenetic analyses, as well as SEM microscopic analysis, revealed the presence of two Setaria species: S. cervi and S. tundra. Setaria tundra was noted in only one individual, a calf of the red deer, while S. cervi was observed in three stages, two hinds and one calf of the red deer. According to our knowledge, it is the first case of S. cervi in the red deer in Poland confirmed in molecular studies and also the first case of S. tundra infection in the red deer.

Candidatus Dirofilaria hongkongensis as Causative Agent of Human Ocular Filariosis after Travel to India.

We report a human case of ocular Dirofilaria infection in a traveler returning to Austria from India. Analysis of mitochondrial sequences identified the worm as Candidatus Dirofilaria hongkongensis, a close relative of Dirofilaria repens, which was only recently described in Hong Kong and proposed as a new species.

Morphological and molecular characteristics of Malayfilaria sofiani Uni, Mat Udin & Takaoka n. g., n. sp. (Nematoda: Filarioidea) from the common treeshrew Tupaia glis Diard & Duvaucel (Mammalia: Scandentia) in Peninsular Malaysia.

BACKGROUND: The filarial nematodes Wuchereria bancrofti (Cobbold, 1877), Brugia malayi (Brug, 1927) and B. timori Partono, Purnomo, Dennis, Atmosoedjono, Oemijati & Cross, 1977 cause lymphatic diseases in humans in the tropics, while B. pahangi (Buckley & Edeson, 1956) infects carnivores and causes zoonotic diseases in humans in Malaysia. Wuchereria bancrofti, W. kalimantani Palmieri, Pulnomo, Dennis & Marwoto, 1980 and six out of ten Brugia spp. have been described from Australia, Southeast Asia, Sri Lanka and India. However, the origin and evolution of the species in the Wuchereria-Brugia clade remain unclear. While investigating the diversity of filarial parasites in Malaysia, we discovered an undescribed species in the common treeshrew Tupaia glis Diard & Duvaucel (Mammalia: Scandentia). METHODS: We examined 81 common treeshrews from 14 areas in nine states and the Federal Territory of Peninsular Malaysia for filarial parasites. Once any filariae that were found had been isolated, we examined their morphological characteristics and determined the partial sequences of their mitochondrial cytochrome c oxidase subunit 1 (cox1) and 12S rRNA genes. Polymerase chain reaction (PCR) products of the internal transcribed spacer 1 (ITS1) region were then cloned into the pGEM-T vector, and the recombinant plasmids were used as templates for sequencing. RESULTS: Malayfilaria sofiani Uni, Mat Udin & Takaoka, n. g., n. sp. is described based on the morphological characteristics of adults and microfilariae found in common treeshrews from Jeram Pasu, Kelantan, Malaysia. The Kimura 2-parameter distance between the cox1 gene sequences of the new species and W. bancrofti was 11.8%. Based on the three gene sequences, the new species forms a monophyletic clade with W. bancrofti and Brugia spp. The adult parasites were found in tissues surrounding the lymph nodes of the neck of common treeshrews. CONCLUSIONS: The newly described species appears most closely related to Wuchereria spp. and Brugia spp., but differs from these in several morphological characteristics. Molecular analyses based on the cox1 and 12S rRNA genes and the ITS1 region indicated that this species differs from both W. bancrofti and Brugia spp. at the genus level. We thus propose a new genus, Malayfilaria, along with the new species M. sofiani.

Molecular identification and phylogenetic analysis of Dipetalonema evansi (LEWIS, 1882) in camels (Camelus dromedarius) of Iran.

Despite the economic importance of camels, the parasites that affect them have not received adequate attention so far and molecular studies are scarce compared to other livestock. In this study, we characterized peripheral blood microfilariae in 200 healthy one-humped camels (Camelus dromedarius) from south-east Iran by microscopy and molecular tools to receive a more detailed insight into prevalence and species that affect them. Moreover, adult specimens of the filarial nematode Dipetalonema evansi were collected from the carcass of an infected animal. Microscopic examination was performed on Giemsa-stained blood smears, and blood was also spotted on Whatman FTA(®) cards for DNA analysis. Genomic DNA was extracted, and PCR was carried out for the detection of filaroid helminths, followed by sequence analysis of positive samples. Four samples were positive for microfilariae by microscopy, while 16 animals (8 %) were positive by PCR. Sequence analysis revealed D. evansi in all cases. Phylogenetic analysis of a cytochrome C oxidase subunit I (COI) sequence of filaroid nematodes showed that most species in a single genus cluster in the same clade; however, D. evansi and D. gracile are not monophyletic and branch rather at the base of the tree. Further studies on the life cycle of D. evansi, specifically the identification of intermediate host(s), have become feasible with the provision of the first specific COI sequences in this study.

Situational analysis of lymphatic filariasis morbidity in Ahanta West District of Ghana.

OBJECTIVES: Situational analysis of lymphatic filariasis (LF) morbidity and its management in Ahanta West, Ghana, to identify potential barrier to healthcare for LF patients. METHODS: Lymphoedema and hydrocoele patients were identified by community health workers from a subset of villages, and were interviewed and participated in focus group discussions to determine their attitudes and practices towards managing their morbidity, and their perceived barriers to accessing care. Local health professionals were also interviewed to obtain their views on the availability of morbidity management services in the district. RESULTS: Sixty-two patients (34 lymphoedema and 28 hydrocoeles) and 13 local health professionals were included in the study. Lymphoedema patients predominantly self-managed their conditions, which included washing with soap and water (61.8%), and exercising the affected area (52.9%). Almost 65% of patients had sought medical assistance at some stage, but support was generally limited to receiving tablets (91%). Local health professionals reported rarely seeing lymphoedema patients, citing stigma and lack of provisions to assist patients as a reason for this. Almost half of hydrocoele patients (44%) chose not to seek medical assistance despite the negative impact it had on their lives. Whilst surgery itself is free with national health insurance, 63% those who had not sought treatment stated that indirect costs of surgery (travel costs, loss of earnings, etc.) were the most prohibitive factor to seeking treatment. CONCLUSIONS: The information obtained from this study should now be used to guide future morbidity strategies in building a stronger relationship between the local health services and LF patients, to ultimately improve patients' physical, psychological and economic wellbeing.