A nurse led intermediate care package in patients who have been hospitalised with an acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVES

To determine the effects of a nurse led intermediate care programme in patients who have been hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

DESIGN

Randomised controlled trial.

SETTING

Community and hospital care in west London.

PARTICIPANTS

122 patients with COPD.

INTERVENTION

A care package incorporating initial pulmonary rehabilitation and self-management education, provision of a written, personalised COPD action plan, monthly telephone calls and 3 monthly home visits by a specialist nurse for a period of 2 years.

MAIN OUTCOME MEASURE

Hospital readmission rate.

SECONDARY OUTCOMES

Unscheduled primary care consultations and quality of life.

RESULTS

There were no differences in hospital admission rates or in exacerbation rates between the two groups. Self-management of exacerbations was significantly different and the intervention group were more likely to be treated with oral steroids alone or oral steroids and antibiotics, and the initiators of treatment for exacerbations were statistically more likely to be the patients themselves. 12 patients in the control group died during the 2 year period, eight as a result of COPD, compared with six patients in the intervention group, of whom one died from COPD. This is a significant difference. When the numbers were adjusted to reflect the numbers still alive at 2 years, in the intervention group patients reported a total of 171 unscheduled contacts with their general practitioner (GP) and in the control group, 280 contacts. The number needed to treat was 0.558--ie, for every one COPD patient receiving the intervention and self-management advice, there were 1.79 fewer unscheduled contacts with the GP.

CONCLUSIONS

An intermediate care package incorporating pulmonary rehabilitation, self-management education and the receipt of a written COPD action plan, together with regular nurse contact, is associated with a reduced need for unscheduled primary care consultations and a reduction in deaths due to COPD but did not affect the hospital readmission rate.

Longitudinal molecular epidemiological analysis of feline calicivirus infection in an animal shelter: a model for investigating calicivirus transmission within high-density, high-turnover populations

The control of outbreaks of calicivirus infection in high-density, high-throughput populations is a challenge to both human and veterinary medicine. In such populations, the prevalence of infection is, in part, dependent on the levels of biosecurity and how this affects virus transmission. Here we show how longitudinal analysis of feline calicivirus (FCV) infection in an animal rescue shelter can be used as a model to examine the dynamics of calicivirus transmission and evolution in such environments. FCV was isolated from 33 of 116 cats sampled over a 15-month period (overall prevalence, 28%). Sequence analysis of the immunodominant variable regions of the viral capsid gene identified 16 strains circulating in the shelter, with no single strain appearing to predominate. The majority of these strains were introduced into the shelter from the community and did not appear to be transmitted within the population. However, for three of these strains, putative transmission events within the shelter were identified. The rates of evolution within hypervariable regions of the FCV capsid gene in individual cats ranged from 0.05 to 1.4% per week, with the highest rates generally being found in animals that either acquired the virus while in the shelter or were undergoing acute infection. These data suggest that despite the high prevalence and presence of multiple strains of FCV within the shelter, the spread of such pathogens may be restricted by various control measures, including good hygiene and biosecurity.

Lethal outbreak of disease associated with feline calicivirus infection in cats

Recently, in the USA, virulent mutants of feline calicivirus (FCV) have been identified as the cause of a severe and acute virulent systemic disease, characterised by jaundice, oedema and high mortality in groups of cats. This severe manifestation of FCV disease has so far only been reported in the USA. However, in 2003, an outbreak of disease affected a household of four adult cats and an adult cat from a neighbouring household in the UK. Three of the adult cats in the household and the neighbouring cat developed clinical signs including pyrexia (39.5 to 40.5 degrees C), lameness, voice loss, inappetence and jaundice. One cat was euthanased in extremis, two died and one recovered. A postmortem examination of one of the cats revealed focal cellulitis around the right hock and right elbow joints. The principal finding of histopathological examinations of selected organs from two of the cats was disseminated hepatocellular necrosis with mild inflammatory infiltration. Immunohistology identified FCV antigen in parenchymal and Kupffer cells in the liver of both animals and in alveolar macrophages of one of them. In addition, calicivirus-like particles were observed by electron microscopy within the hepatocytes of one cat. FCV was isolated from two of the dead cats and from the two surviving cats. Sequence analysis showed that they were all infected with the same strain of virus, but that it was different from strains of FCV associated with the virulent systemic disease in cats in the USA. The outbreak was successfully controlled by quarantine in the owner's house.

Loss of heterozygosity at the BRCA2 locus is a common finding in prostate cancer in men with a germline BRCA2 mutation

10539

Background: The prevalence of prostate cancer (PC) is higher in men with a germline mutation in BRCA2 and to a lesser extent BRCA1. It is unclear as to whether a causal relationship exists between these mutations and PC tumorigenesis. The primary aim of this pilot study was to examine for loss of heterozygosity (LOH) in PC samples from men with a known BRCA1/2 mutation. Secondary aims included assessment of the clinical and pathological features of PC in these individuals. Methods: Subjects were male carriers of a germline BRCA1/2 mutation enrolled in kConFab with a diagnosis of PC. LOH analysis was performed using multiplex ligation-dependent probe amplification and confirmed using PCR and sequencing. Clinical data was obtained on all individuals together with histopathology review. Results: In total, 134 pedigrees from BRCA1/2 mutation positive families known to include = 1men with PC were reviewed; 192 men were identified as having PC, however, only 26 were found to carry a pathogenic family specific mutation. Of these, 14 were ineligible as prostate tissue was unavailable. LOH was therefore assessed in 12 subjects (3 BRCA1 and 9 BRCA2). LOH at the BRCA2 locus was seen in 8/9 (89%) subjects with a BRCA2 mutation whilst the ninth showed no LOH. None of the samples from BRCA1 carriers were found to have LOH at the BRCA1 locus. For samples showing LOH, sequencing confirmed loss of the wild-type allele. No unique clinical or histopathological subtype was identified. Conclusions: LOH appears to occur very frequently at the BRCA2 locus in PC arising in men known to carry a germline BRCA2 mutation with LOH heavily biased towards loss of the wild-type allele. Whilst the cohort studied is small, these two results strongly indicate that BRCA2 is a tumour suppressor of PC and is the first gene shown to have this property. In contrast, failure to identify LOH in the BRCA1 samples suggests that BRCA1 is unlikely to be integral in the development of PC. These results should be confirmed in a larger cohort and further research into the mechanisms of BRCA2 induced prostate tumorigenesis is warranted.

No significant financial relationships to disclose.

Factors associated with dog ownership and contact with dogs in a UK community

BACKGROUND

Dogs are popular pets in many countries. Identifying differences between those who own dogs or have contact with dogs, and those who do not, is useful to those interested in the human-animal bond, human health and for provision of veterinary services. This census-based, epidemiological study aimed to investigate factors associated with dog ownership and contact with dogs, in a semi-rural community of 1278 households in Cheshire, UK.

RESULTS

Twenty-four percent of households were identified as dog-owning and 52% owned a pet of some type. Multivariable logistic regression suggested that households were more likely to own a dog if they had more occupants (five or more); if they had an adult female household member; or if they owned a horse. The age structure of the households was also associated with dog ownership, with households containing older children (between six and 19 years of age) and young adults (between 20 and 29 years of age), more likely to own dogs. We also found that dog owning households were more likely to be multi-dog households than single-dog if they also owned a cat or a bird, or if the household contained a person of 20-29 years old. Dog owners reported increased contact with dogs, other than their own, compared to those that did not own dogs and this contact appeared to be mainly through walking.

CONCLUSION

Some household types are more likely to own a dog than others. This study supports the suggestion that dogs are more common in families who have older children (6-19 years), as has been generally observed in other countries. Dog owners are also more likely to have contact with dogs other than their own, compared with those not owning a dog.

Factors associated with dog ownership and contact with dogs in a UK community

BACKGROUND

Dogs are popular pets in many countries. Identifying differences between those who own dogs or have contact with dogs, and those who do not, is useful to those interested in the human-animal bond, human health and for provision of veterinary services. This census-based, epidemiological study aimed to investigate factors associated with dog ownership and contact with dogs, in a semi-rural community of 1278 households in Cheshire, UK.

RESULTS

Twenty-four percent of households were identified as dog-owning and 52% owned a pet of some type. Multivariable logistic regression suggested that households were more likely to own a dog if they had more occupants (five or more); if they had an adult female household member; or if they owned a horse. The age structure of the households was also associated with dog ownership, with households containing older children (between six and 19 years of age) and young adults (between 20 and 29 years of age), more likely to own dogs. We also found that dog owning households were more likely to be multi-dog households than single-dog if they also owned a cat or a bird, or if the household contained a person of 20-29 years old. Dog owners reported increased contact with dogs, other than their own, compared to those that did not own dogs and this contact appeared to be mainly through walking.

CONCLUSION

Some household types are more likely to own a dog than others. This study supports the suggestion that dogs are more common in families who have older children (6-19 years), as has been generally observed in other countries. Dog owners are also more likely to have contact with dogs other than their own, compared with those not owning a dog.

Feline herpesvirus

Feline herpesvirus (FHV-1; felid herpesvirus 1 (FeHV-1)) is an alphaherpesvirus of cats closely related to canine herpesvirus-1 and phocine herpesvirus-1. There is only one serotype of the virus and it is relatively homogenous genetically. FeHV-1 is an important cause of acute upper respiratory tract and ocular disease in cats. In addition, its role in more chronic ocular disease and skin lesions is increasingly being recognised. Epidemiologically, FeHV-1 behaves as a typical alphaherpesvirus whereby clinically recovered cats become latently infected carriers which undergo periodic episodes of virus reactivation, particularly after a stress. The primary site of latency is the trigeminal ganglion. Conventional inactivated and modified-live vaccines are available and protect reasonably well against disease but not infection, although viral shedding may be reduced. Genetically engineered vaccines have also been developed, both for FeHV-1 and as vector vaccines for other pathogens, but none is as yet marketed.

Feline calicivirus

Feline calicivirus (FCV) is an important and highly prevalent pathogen of cats. It belongs to the family Caliciviridae which includes other significant pathogens of man and animals. As an RNA virus, high polymerase error rates convey upon FCV a high genome plasticity, and allow the virus to respond rapidly to environmental selection pressures. This makes the virus very adaptable and has important implications for clinical disease and its control. Being genetically diverse, FCV is associated with a range of clinical syndromes from inapparent infections to relatively mild oral and upper respiratory tract disease with or without acute lameness. More recently, highly virulent forms of the virus have emerged associated with a systemic infection that is frequently fatal. A proportion of FCV infected cats that recover from acute disease, remain persistently infected. In such cats, virus evolution is believed to help the virus to evade the host immune response. Such long-term carriers may only represent a minority of the feline population but are likely to be crucial to the epidemiology of the virus. Vaccination against FCV has been available for many years and has effectively reduced the incidence of clinical disease. However, the vaccines do not prevent infection and vaccinated cats can still become persistently infected. In addition, FCV strain variability means that not all strains are protected against equally. Much progress has been made in understanding the biology and pathogenesis of this important feline virus. Challenges for the future will necessarily focus on how to control the variability of this virus particularly in relation to emerging virulent strains and vaccination.

Feline herpesvirus

Feline herpesvirus (FHV-1; felid herpesvirus 1 (FeHV-1)) is an alphaherpesvirus of cats closely related to canine herpesvirus-1 and phocine herpesvirus-1. There is only one serotype of the virus and it is relatively homogenous genetically. FeHV-1 is an important cause of acute upper respiratory tract and ocular disease in cats. In addition, its role in more chronic ocular disease and skin lesions is increasingly being recognised. Epidemiologically, FeHV-1 behaves as a typical alphaherpesvirus whereby clinically recovered cats become latently infected carriers which undergo periodic episodes of virus reactivation, particularly after a stress. The primary site of latency is the trigeminal ganglion. Conventional inactivated and modified-live vaccines are available and protect reasonably well against disease but not infection, although viral shedding may be reduced. Genetically engineered vaccines have also been developed, both for FeHV-1 and as vector vaccines for other pathogens, but none is as yet marketed.

Jaundice, renal failure and pulmonary haemorrhage in a canal boat owner

Leptospirosis is a rare notifiable disease with three major clinical manifestations: subclinical disease, a self limiting illness (90% cases) and Weil's disease, a fulminant, life-threatening condition with renal and hepatic failure, haemorrhagic pneumonitis and cardiovascular collapse. Diagnosis is by the detection of IgM antibodies to leptospira produced 7 to 14 days after the onset of illness. It is important for acute physicians to consider this condition in their initial differential diagnosis since early treatment reduces the severity and duration of symptoms and hospital stay. A history of environmental or occupational exposure to animals or potentially infected water should raise suspicions of leptospirosis. This article aims to remind clinicians of the diagnosis and management of this condition. The typical symptoms and signs are illustrated by a recent case which presented to our department.

Evolutionary mechanisms of persistence and diversification of a calicivirus within endemically infected natural host populations

In order to understand the evolutionary mechanisms of persistence and diversification within the Caliciviridae, we have been exploiting endemic infection of feline calicivirus within five geographically distinct household groups of cats. By sequencing immunodominant and variable regions of the capsid gene, we identified the relative contribution of the different evolutionary processes employed by the virus to ensure its long-term survival in the host population. Such strategies included progressive evolution of a given variant of a strain through mutation accumulation within an individual, sequential reinfection with either a variant of the same strain or with a different strain, and mixed infection. Recombination between different strains in this study has been reported in detail elsewhere (K. P. Coyne et al., J. Gen. Virol. 87:921-926, 2006). Here, we provide evidence to suggest that true long-term persistent infection in individuals is relatively rare, with the majority of apparent viral carriers undergoing a combination of progressive evolution and cyclical reinfection. Progressive evolution at the individual level and variant reinfection at both the individual and population levels were associated with positive selection. Two measures of evolution rate were determined; for a virus progressively evolving within an individual (1.32 x 10(-2) to 2.64 x 10(-2) substitutions per nucleotide per year, i.e., no transmission) and for a strain circulating within a population (3.84 x 10(-2) to 4.56 x 10(-2) substitutions per nucleotide per year, i.e., including transmission). Reiteration of both progressive evolution and variant reinfection appeared to lead to a gradual increase in the diversity of a given strain of virus, both in the individual and in the population, until eventually new strains emerged.

Long-term analysis of feline calicivirus prevalence and viral shedding patterns in naturally infected colonies of domestic cats

Feline calicivirus (FCV) is a highly infectious respiratory pathogen of domestic cats. The prevalence of FCV in the general cat population is high, particularly in multi-cat households, largely because many clinically recovered cats remain persistently infected carriers. In order to assess how FCV circulates in such groups and to assess the contribution that each individual animal makes to the epidemiology of the disease, we have carried out the first detailed analysis of long-term shedding patterns of FCV in individual cats within naturally infected colonies. The prevalence of FCV in each of the groups on individual sampling occasions ranged from 0% to 91%, with averages for the individual colonies ranging from 6% to 75%. Within each of the colonies, one to three distinct strains of FCV were identified. Individual cats showed a spectrum of FCV shedding patterns over the sampling period which broadly grouped into three categories: those that shed virus relatively consistently, those that shed virus intermittently, and those that appeared never to shed virus. This is the first report identifying non-shedder cats that appear resistant to FCV infection over long periods of time, despite being continually exposed to virus. Such resistance appeared to be age related, which may have been immune-mediated, although by analogy with other caliciviruses, factors such as host genetic resistance may play a role. Given that a proportion of the population appears to be resistant to infection, clearly the cohort of cats that consistently shed virus are likely to provide an important mechanism whereby infection can be maintained in small populations.

Cancer risk management practices of non-carriers within BRCA1/2 mutation positive families in the Kathleen Cunningham Consortium for Research into Familial Breast Cancer (kConFab)

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Background: This study prospectively evaluated risk management practices of true BRCA1/2 negative women. Methods: A questionnaire was mailed to 471 non-carriers from mutation positive families 3 years after their enrolment in the kConFab breast cancer (BC) family cohort study. Women who had received their mutation result had pre-test counselling and result disclosure in one of 16 Family Cancer Clinics nationwide. Undertaking mammography more often than 2 yearly (Australian population guidelines), clinical breast examination (CBE) more often than yearly, breast self-examination (BSE) more often than monthly and any trans-vaginal ultrasound (TVU) or CA-125 was considered over screening. Linear logistic regression was used to identify factors (age, marital status, education, parity, ethnicity, place of residence, time since disclosure of result, family history) associated with over screening. Results: 347 women responded (74%); 260 were excluded from this analysis (self-reported not knowing their mutation status, 207; uninformative screening data due to proximity of result disclosure to questionnaire administration, 47; developed cancer, 3; pregnancy, 3), leaving 87 subjects. Mean follow up was 4.4 years. Proportions over-screening were; mammography 53%, CBE 10%, BSE 11%, TVU 10% and CA125 10%. No measured factor was associated with over-utilization of BC screening. Women with > one relative with OC were significantly more likely to over-utilize TVU (OR 8.1, CI 1.6–42 P=0.01) and CA125 (OR 19.6, CI 3.1–121 P=0.001) compared to women with ≤ one relative with OC. One woman underwent bilateral mastectomy and 1 bilateral oophorectomy; none used chemoprevention. Conclusions: A major benefit of learning one′s negative mutation status is that the intensity of risk management practices can be reduced to that appropriate for the general population. However, non-carriers with a strong family history of OC tend to inappropriately use OC screening. The reasons are unclear but need elucidation given the potential for harm. The reasons for over-utilization of mammography in 53% also warrant further study.

No significant financial relationships to disclose.

Circadian distribution of hematology variables in subjects with multiple sclerosis

Hematology variables were measured in blood samples obtained every 3h (8/24h) from 10 multiple sclerosis (MS) patients and 34 healthy subjects and analyzed for circadian characteristics using the population multiple-components method. Red blood cell (RBC) and hemoglobin levels as well as hematocrits exhibited circadian rhythms with minimal amplitudes in healthy individuals and insignificant variability in the smaller group of MS patients. In contrast the total white blood cell (WBC) and platelet counts for MS patients and healthy individuals both showed significant circadian characteristics while the mean 24h WBC and platelet levels did not significantly differ between the two groups. When the different WBC subsets were examined independently, statistically significant circadian rhythms were seen for lymphocytes and eosinophils for both MS patients and healthy individuals and for neutrophils only in the latter. Moreover, the 24h mean levels of lymphocytes, basophils, and eosinophils were significantly higher for the healthy controls while those of monocytes were higher for the MS patients. However, of all the variables tested with significant circadian rhythms in both groups of individuals, only those of lymphocyte numbers exhibited different patterns with somewhat higher amplitude in healthy individuals and a peak level occurring over an hour after that of MS patients. These changes may be the reflection of a disturbance in the regulation of patterns of lymphocyte activity and migration in MS patients. In addition, the elevation in circulating monocytes in MS patients is consistent with the inflammatory nature of the disease.

The challenge for the next generation of feline calicivirus vaccines

Feline calicivirus (FCV) has been shown to evolve within individual cats and in the environment of colonies. This evolution and the diversity it creates has important clinical implications, not only for the disease in cats, but also for attempts to control disease by vaccination. Generally speaking, existing vaccines appear to be very effective at controlling the majority of clinical disease. However, some concerns remain including a failure to induce sterilising immunity, occasional vaccine breakdowns, and for live vaccines, occasional vaccine-induced disease. Key areas for future vaccine development include monitoring and broadening the cross-reactivity of vaccine immunity to field viruses, especially the recently evolved highly virulent strains, and attempting to reduce/eliminate field virus shedding by vaccinated cats.

Duration of immunity (DOI)--The regulatory issues

This paper discusses the efficacy of cat and dog vaccines, with respect to duration of immunity and regulatory issues. The European Union (EU) regulatory requirements are described: briefly, efficacy claims, which include duration of immunity, have to be specific for the product and supported by controlled laboratory and field trials. As a result, the duration of immunity shown has typically been a minimum, because of the cost and welfare implications of keeping animals for long periods of time in isolation. In contrast, in the US, duration of immunity has not traditionally been required for each individual product, only for rabies vaccines and some other vaccines for which no other products are available. The consequence of this is that in the US, various scientific authorities have produced guidelines appropriate for individual diseases. Undoubtedly this will continue, although the regulatory authorities also appear to be moving towards a position where lack of information may be indicated on the product label, and studies are required to support extended duration of immunity claims. The advantages and disadvantages of laboratory challenge studies versus field trials are discussed, and the use of alternatives such as surrogate markers of protection. The approaches used for small animal vaccines are compared to those used, for example, in human medicine. The main issue for small animals is that unlike in some other species, the aim generally is to maximise protection in the individual, rather than induce protection at the population level. The drawbacks of the present EU system are summarised, and the ways in which the situation is currently being approached and improved are presented.

Recombination of Feline calicivirus within an endemically infected cat colony

To understand the evolution of the family Caliciviridae, the persistence of Feline calicivirus (FCV) was studied within an endemically infected cat colony. Polymerase and capsid sequences were analysed for 34 FCV isolates obtained over a 4 year period. Initially, the colony was infected with one strain of virus, but a second distinct strain was later identified. Subsequently, the emergence of a recombinant virus was observed, containing elements of both of the strains circulating within the colony. The recombination event mapped close to the ORF1/ORF2 junction. This is consistent with recombination in other caliciviruses, suggesting a common mechanism within this family. This is the first report of recombination within the genus Vesivirus in the family Caliciviridae and the first time that a recombination event has been observed where the parental strains have also been identified.

Methicillin-resistant staphylococci in companion animals

We determined the molecular characteristics of methicillin-resistant staphylococci from animals and staff at a small animal and equine hospital. Methicillin-resistant Staphylococcus aureus (MRSA) identical to human EMRSA-15 was found in dogs and hospital staff. In contrast, 5 distinct MRSA strains were isolated from horses but not from hospital staff.

Sirolimus conversion after liver transplantation: improvement in measured glomerular filtration rate after 2 years

METHODS

We reviewed our prospectively maintained database of 2005 liver transplantations. Therapy was either started de novo or converted from calcineurin inhibitors (CNIs) to sirolimus as the main immunosuppressive agent for nephrotoxicity or rejection. Glomerular filtration rate (GFR) was determined with iodine 125-labeled sodium isthalamate (Glofil-125), and serum creatinine concentration was obtained before and 3 months after transplantation, and yearly in both groups. Sirolimus levels were 10 to 15 ng/mL in patients at less than 3 months after transplantations and 5 to 10 ng/mL in the remaining patients. All patients received mycophenolate mofetil as maintenance therapy.

RESULTS

Data for 29 patients in the de novo group and 35 in the conversion group were reviewed. Patients in the de novo group demonstrated an acute cellular rejection rate of 17.2%, 40% of which were steroid resistant. In this group, 48.2% discontinuation of sirolimus was necessary because of adverse effects. Patients in the conversion group demonstrated an acute cellular rejection rate of 2.8% and a 34.3% rate of sirolimus discontinuation. Seventeen (56.7%) patients at 1 year and 8 (44.4%) patients at 2 years demonstrated continued improvement in GFR. In the conversion group, case-control analysis did not demonstrate a significant difference in GFR and serum creatinine concentration (P > .05) at 1 and 2 years after conversion. At the time of review, no patients in the conversion group required hemodialysis.

CONCLUSIONS

Conversion to sirolimus therapy is an effective strategy in improving renal function in patients with CNI-induced nephrotoxicity and can be done without increased rejection. Most of our patients (65.7%) tolerated sirolimus conversion. Of these, 56.7% and 44.4% demonstrated continued increase in GFR with the CNI-free regimen at 1 and 2 years, respectively. Long-term, large-population, prospective, randomized, controlled studies should further validate these results.

Circadian distribution of iron and ferritin in serum of healthy and type 2 diabetic males

AIM

We examined the circulating levels of iron and ferritin in serum of seven healthy and three insulin non-dependent diabetic (Type 2) males in order to compare their circadian characteristics.

METHODS

Blood samples were collected every 3h over a 24h period and were analyzed for serum iron and ferritin.

RESULTS

The mean Fe level was significantly higher in healthy than in diabetic subjects: 80.0 +/- 3.3 vs. 63.0 +/- 3.7 microg/dL. The ferritin level was significantly lower in healthy than in diabetic men: 79.8 +/- 4.7 vs. 186.3 +/- 110.5 microg/L. A significant (p < 0.001) time-effect was found by ANOVA and circadian rhythm was detected at p < 0.001 in all data sets when a 24h cosine was fitted to the normalized data. Acrophases were located in mid to late morning for Fe (11:30, vs. 09:22h) and for ferritin (11:10 vs. 11:46h).

DISCUSSION

We concluded that there is significant circadian variation in both serum Fe and ferritin, with predictable peaks in the mid to late morning.

Construct and face validity of MIST-VR, Endotower, and CELTS

BACKGROUND

Video trainers may best offer visually realistic laparoscopic simulation, whereas virtual reality (VR) modules may best provide multidimensional objective measures of performance. This study compares the construct and face validity of three different laparoscopic simulators.

METHODS

Subjects were voluntarily enrolled at the Learning Center during the 2004 SAGES annual meeting. Each subject completed two repetitions of a single task on each of three simulators, MIST-VR, Endotower, and CELTS; performance scores were automatically generated and recorded. Scores of individuals with various levels of experience were compared to determine construct validity for each simulator. Experience was defined according to four parameters: (a) PGY level, (b) fellowship training, (c) basic laparoscopic cases, and (d) advanced laparoscopic cases. Subjects rated each simulator regarding six face validity (realism of simulation) parameters using a 10-point Likert scale (10 = best rating) and participant scores were compared to previously established expert scores (proficiency goals for training).

RESULTS

Ninety-one attendees completed the study. Construct validity was demonstrated for all three simulators; significant differences in scores were detected according to one parameter for MIST-VR, two parameters for Endotower, and all four parameters for CELTS. Face validity was rated as good to excellent for all three simulators (7.0 +/- 0.3 for MIST-VR, 7.9 +/- 0.3 for Endotower [p < 0.001 vs MIST-VR], and 8.7 +/- 0.1 for CELTS [p = 0.001 vs MIST-VR, p = 0.01 vs Endotower]); 6%, 0%, and 36% of "expert" participants obtained expert scores on MIST-VR, Endotower, and CELTS, respectively.

CONCLUSIONS

All three simulators demonstrated significant construct and reasonable face validity. Although virtual reality holds great promise to expand the scope of laparoscopic simulation, current interfaces may limit their utility for assessment. Computer-enhanced video trainers may offer an improved interface while incorporating useful multidimensional metrics. Further work is needed to establish standards for appropriate skills assessment methods and performance levels using simulators.

Diagnostic value of cytology of bronchoalveolar fluid for lung diseases of sheep

Bronchoalveolar lavage fluid was collected postmortem from the lungs of 113 sheep, and total and differential cell counts were analysed in relation to the presence of gross and microscopic lung pathology. The diffuse lung diseases, maedi and adenomatosis, were both characterised by an increase in overall cellularity and by increases in the percentages of lymphocytes and neutrophils, respectively. Focal parasitic lung disease was characterised by an increase in the percentage of eosinophils and mast cells. Consolidated lung lesions were characterised by a slight increase in cellularity but no change in the differential cell profile. In regions of parasitised and consolidated lungs without lesions the differential cell profile was consistent with focal lung pathology, although the slight increase in cellularity observed in the consolidated regions was not observed in the regions without lesions. A decision tree was developed to facilitate the interpretation and indicate the likely predictive capacity of the differential cytology of the fluid.

MELD Scores Do Not Predict Patient Morbidity While on the Liver Transplant Waiting List

The goals of this study were to assess waitlist morbidity in terms of the frequency of health care services utilized by patients while on the liver transplant (LTX) waiting list and to determine whether that utilization can be predicted by the Model for End-Stage Liver Disease (MELD). Sixty-three noncomatose subjects were followed from waitlist placement until death, change in status, LTX, or study discontinuance. Health care events included doctor/clinic visits, labs, outpatient/inpatient tests and procedures, and hospital/intensive care unit days. Listing MELD scores and LTX MELD scores were examined against the number of health care event occurrences within 60 days of listing and 60 days of LTX, respectively, as were changes in MELD scores between listing and LTX and differences in the number of occurrences between the two time points. The only significant correlations noted were between LTX MELD scores and number of hospital days near LTX (r = .360, P = .046) and between LTX MELD scores and the sum total number of occurrences near LTX (r = .370, P = .044). These results suggest that MELD scores do not appear to predict morbidity in terms of health care utilization in patients awaiting LTX. Developing a system capable of predicting waitlist morbidity may lead to the implementation of medical interventions aimed at circumventing foreseeable complications and/or crises in patients awaiting LTX.