Alpha-Gal Bound Aptamer and Vancomycin Synergistically Reduce Staphylococcus aureus Infection In Vivo

Methicillin-resistant Staphylococcus aureus (MRSA) is a pervasive and persistent threat that requires the development of novel therapies or adjuvants for existing ones. Aptamers, small single-stranded oligonucleotides that form 3D structures and can bind to target molecules, provide one possible therapeutic route, especially when presented in combination with current antibiotic applications. BALB/c α-1, 3-galactosyltransferase (-/-) knockout (GTKO) mice were infected with MRSA via tail vein IV and subsequently treated with the αSA31 aptamer (n = 4), vancomycin (n = 12), or αSA31 plus vancomycin (n = 12), with split doses in the morning and evening. The heart, lungs, liver, spleen, and kidneys were harvested upon necropsy for histological and qPCR analysis. All mice treated with αSA31 alone died, whereas 5/12 mice treated with vancomycin alone and 7/12 mice treated with vancomycin plus αSA31 survived the course of the experiment. The treatment of MRSA-infected mice with Vancomycin and an adjuvant aptamer αSA31 reduced disease persistence and dispersion as compared to treatment with either vancomycin SA31 alone, indicating the combination of antibiotic and specifically targeted αSA31 aptamer could be a novel way to control MRSA infection. The data further indicate that aptamers may serve as a potential therapeutic option for other emerging antibiotic resistant pathogens.

The Patient's perspective: A review of the results from a radiotherapy patient experience survey in the North-West of England

INTRODUCTION

A patient experience survey was undertaken for patients completing radiotherapy at the three Northwest of England Radiotherapy Providers.

METHODS

A previously reported National Radiotherapy Patient Experience Survey was adapted and undertaken in the Northwest of England. Quantitative data was analysed to establish trends. Frequency distribution was applied to appraise the number of participants selecting each of the pre-determined responses. Thematic analysis of free text responses was conducted.

RESULTS

The questionnaire received 653 responses from the 3 providers across seven departments. Thematic analysis revealed 3 themes; logistics, information and operational.

CONCLUSION

The results indicate that the majority of patients are satisfied with their treatment and care. Patients' responses indicate areas for improvements. Expectancy theory states that an individual's satisfaction is related to the difference between expected service and the service received. Consequently, when reviewing services and developing improvement it is important to understand patients' expectations^. This regional survey starts to capture what people receiving radiotherapy expect from the service and the professionals delivering their treatment.

IMPLICATIONS FOR PRACTICE

This survey responses make a case for reviewing the information provision pre and post radiotherapy. This includes clarifying the understanding of consent for treatment including the intended benefits and potential late effects. There is an argument to offer information sessions prior to radiotherapy to achieve more relaxed and informed patients. A recommendation from this work is for the radiotherapy community undertake a national radiotherapy patient experience survey, facilitated via the 11 Radiotherapy ODNs. A national radiotherapy survey has multiple benefits to inform improvements in practice. This includes benchmarking services against national averages. This approach is aligned with the principles of the service specification in terms of reducing variation and increasing quality.

Generalized dermatophytosis caused by Trichophyton equinum in 8 juvenile black bears in California

From 2014-2019, 8 juvenile black bears (Ursus americanus) from different geographic regions were presented to the California Department of Fish and Wildlife because of emaciation, alopecia, and exfoliative dermatitis that resulted in death or euthanasia. Autopsy and histopathology revealed that all 8 bears had generalized hyperkeratotic dermatitis, folliculitis, and furunculosis. Skin structures were heavily colonized by fungal hyphae and arthrospores; fungal cultures of skin from 7 bears yielded Trichophyton equinum, a zoophilic dermatophyte reported only rarely in non-equid species. Additional skin conditions included mites (5), ticks (2), and coagulase-negative Staphylococcus sp. infections (2). No other causes of morbidity or mortality were identified. Molecular comparisons performed at the University of Texas Fungal Reference Laboratory determined that all isolates produced identical banding patterns, potentially representing a clonal population. Dermatophytosis is commonly localized and limited to the stratum corneum of the epidermis and hair follicles. Generalized disease with dermal involvement is rare in immunocompetent individuals; illness, malnutrition, age, or immunosuppression may increase susceptibility. Underlying causes for the severe disease impact in these bears were not evident after physical or postmortem examination. The mechanism by which bears from different geographic locations had severe, T. equinum-associated dermatophytosis from a potentially clonal dermatophyte could not be explained and warrants further investigation.

Viruses in unexplained encephalitis cases in American black bears (Ursus americanus)

Viral infections were investigated in American black bears (Ursus americanus) from Nevada and northern California with and without idiopathic encephalitis. Metagenomics analyses of tissue pools revealed novel viruses in the genera Circoviridae, Parvoviridae, Anelloviridae, Polyomaviridae, and Papillomaviridae. The circovirus and parvovirus were of particular interest due to their potential importance as pathogens. We characterized the genomes of these viruses and subsequently screened bears by PCR to determine their prevalence. The circovirus (Ursus americanus circovirus, UaCV) was detected at a high prevalence (10/16, 67%), and the chaphamaparvovirus (Ursus americanus parvovirus, UaPV) was found in a single bear. We showed that UaCV is present in liver, spleen/lymph node, and brain tissue of selected cases by in situ hybridization (ISH) and PCR. Infections were detected in cases of idiopathic encephalitis and in cases without inflammatory brain lesions. Infection status was not clearly correlated with disease, and the significance of these infections remains unclear. Given the known pathogenicity of a closely related mammalian circovirus, and the complex manifestations of circovirus-associated diseases, we suggest that UaCV warrants further study as a possible cause or contributor to disease in American black bears.

Rotavirus A Associated with Clinical Disease and Hepatic Necrosis in California Pigeons (Columba livia domestica)

Retrospective analysis of pigeon necropsy submissions to the California Animal Health and Food Safety Laboratory System from 2000 to 2018 revealed 14 submissions diagnosed with rotavirus A hepatic necrosis or "reoviruslike" viral hepatitis. Nine of the 14 submissions (64%) occurred in 2018. Submissions were racing pigeons and squab breeders from flocks with increased mortality. Juvenile and adult pigeons were submitted with a history of depression, diarrhea, regurgitation, labored breathing, and weakness. Flock morbidity peaked at 80% and mortality at 28%. The most consistent findings on postmortem examination were variably congested, mottled, and enlarged livers and spleens. Microscopically, mild to severe hepatic necrosis was observed with variable bile duct hyperplasia, sinusoidal congestion, hemosiderosis, and portal lymphoplasmacytic inflammation. Rotavirus A was detected in hepatocytes and inflammatory cells by immunohistochemistry. Negative-stain electron microscopy identified viral particles consistent with a member of Reoviridae in all negatively stained liver homogenates. Eleven cases were analyzed by reverse transcriptase-PCR targeting rotavirus A viral protein (VP) 6 and VP7 genes. Subsequent phylogenetic analysis of the VP6 and VP7 sequences compared to published Chinese, Nigerian, and German rotavirus A VP6 and VP7 sequences demonstrated the formation of two and three distinct clades, respectively. To the authors' knowledge, rotavirus A hepatic necrosis in pigeons has not been previously reported in the United States and represents a significant emerging disease for the pigeon industry due to the potential for high flock mortality and lost production.

Intoxication by Astragalus garbancillo var. garbancillo in llamas

Lysosomal storage diseases are inherited and acquired disorders characterized by dysfunctional lysosomes. Intracytoplasmic accumulation of undegraded substrates leads to impaired cellular function and death. Several plant species are toxic to livestock because of the presence of indolizidine alkaloids, including swainsonine, which cause a storage disease. Swainsonine-induced nervous disease (i.e., locoism) of sheep and cattle is well recognized in several parts of the world, particularly in the western United States and in parts of Australia. Spontaneous intoxication by Astragalus garbancillo var. garbancillo was suspected in a group of 70 llamas (Lama glama) in Jujuy Province, northwestern Argentina. The animals grazed an area dominated by stands of A. garbancillo var. garbancillo. Clinical signs were staggering, ataxia, hypermetria, and progressive weight loss. The clinical course in individual animals was ~50 d. The main microscopic changes were Purkinje cell degeneration, necrosis, and loss, associated with intracytoplasmic vacuolation, meganeurite formation, and Wallerian degeneration. Specific positive labeling for ubiquitin was observed in axonal spheroids. Composite leaf and stem samples of A. garbancillo var. garbancillo analyzed by high-performance liquid chromatography contained 0.03% swainsonine. Based on the microscopic lesions, clinical history, and plant analysis, a diagnosis was made of storage disease caused by consumption of swainsonine-containing A. garbancillo var. garbancillo.

On the use of flexible excess hazard regression models for describing long-term breast cancer survival: a case-study using population-based cancer registry data

BACKGROUND

Breast cancer prognosis has dramatically improved over 40 years. There is, however, no proof of population 'cure'. This research aimed to examine the pattern of long-term excess mortality due to breast cancer and evaluate its determinants in the context of cancer registry data.

METHODS

We used data from the Geneva Cancer Registry to identify women younger than 75 years diagnosed with invasive, localised and operated breast cancer between 1995 and 2002. Flexible modelling of excess mortality hazard, including time-dependent (TD) regression parameters, was used to estimate mortality related to breast cancer. We derived a single "final" model using a backward selection procedure and evaluated its stability through sensitivity analyses using a bootstrap technique.

RESULTS

We analysed data from 1574 breast cancer women including 351 deaths (22.3%). The model building strategy retained age at diagnosis (TD), tumour size and grade (TD), chemotherapy and hormonal treatment (TD) as prognostic factors, while the sensitivity analysis on bootstrap samples identified nodes involvement and hormone receptors (TD) as additional long-term prognostic factors but did not identify chemotherapy and hormonal treatment as important prognostic factors.

CONCLUSIONS

Two main issues were observed when describing the determinants of long-term survival. First, the modelling strategy presented a lack of robustness, probably due to the limited number of events observed in our study. The second was the misspecification of the model, probably due to confounding by indication. Our results highlight the need for more detailed data and the use of causal inference methods.

Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland

BACKGROUND

Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery.

METHODS

The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future.

RESULTS

Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems.

CONCLUSIONS

The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

Abortion and Ulcerative Posthitis Associated with Caprine Herpesvirus–1 Infection in Goats in California

Three outbreaks of late-gestation abortions in does and ulcerative posthitis in bucks, associated with caprine herpes virus–1 (CHV-1), in California are described. In herd A, 10 of 17 does aborted in a 7-day period, whereas in herd B, 4 of 130 does aborted in a 45-day period and in herd C, 100 of 300 does aborted in a 3-week period. Most fetuses had multifocal pinpoint depressed foci with a zone of hyperemia on external and cut surfaces of the kidneys, liver, lungs, and adrenal glands. Histologically, scattered multifocal areas of necrosis with mild neutrophilic infiltrate were observed in kidneys, brain, liver, adrenal glands, and lungs of most fetuses of the 3 herds. Large amphophilic intranuclear inclusion bodies, which displaced the chromatin, were observed in cells within and around the necrotic foci in kidneys and adrenal glands. Particles 85–113 nm in size with morphology compatible with herpes virus were observed in the nuclei of these cells when examined by electron microscopy. Irregular, shallow, red ulcers were observed in the prepuce of 1 buck from herd C. Prepuce biopsies from this animal had necrosis of the superficial mucosal epithelium and severe submucosal lymphoplasmocytic infiltrates. Large intranuclear amphophilic inclusion bodies were observed in most cells of the stratum spinosum of the preputial epithelium, but no viral particles were observed in these cells. Caprine herpes virus–1 was isolated from tissue pools of fetuses from the 3 herds but not from prepuce biopsies. Positive results were obtained when tissues of a fetus from herd C were processed by a polymerase chain reaction technique to amplify the amino terminus of the glycoprotein C gene of CHV-1. Sera from aborted does from herds B and C and from the 3 bucks from herd C had high antibody titers to CHV-1. The results presented here support the hypothesis that the male goat is involved in the transmission of CHV-1. However, other forms of transmission cannot be ruled out.

Exotic pediculosis and hair-loss syndrome in deer (Odocoileus hemionus) populations in California

Infestation with nonnative, “exotic” lice was first noted in Washington black-tailed deer ( Odocoileus hemionus columbianus) in 1994 and has since then spread throughout the western United States. In California, infestation with the exotic louse Damalinia ( Cervicola) sp. was first detected in black-tailed deer from northern California in 2004, and, in 2009, the exotic louse species Bovicola tibialis and Linognathus africanus were identified on mule deer ( Odocoileus hemionus californicus) in central Sierra Nevada in association with a mortality event. Exotic lice have since been detected in various locations throughout the state. We describe the geographic distribution of these exotic lice within California, using data from 520 live-captured and 9 postmortem-sampled, free-ranging mule deer examined between 2009 and 2014. Data from live-captured deer were used to assess possible associations between louse infestation and host age, host sex, migratory behavior, season, and blood selenium and serum copper concentrations. Damalinia ( Cervicola) sp. and B. tibialis lice were distinctively distributed geographically, with D. ( Cervicola) sp. infesting herds in northern and central coastal California, B. tibialis occurring in the central coastal mountains and the Sierra Nevada, and L. africanus occurring only sporadically. Younger age classes and low selenium concentrations were significantly associated with exotic louse infestation, whereas no significant relationship was detected with serum copper levels. Our results show that exotic lice are widespread in California, and younger age classes with low blood selenium concentrations are more likely to be infested with lice than older deer.

Fatty Liver Hemorrhagic Syndrome in the Backyard Chicken

Fatty liver hemorrhagic syndrome, characterized by sudden death in overconditioned hens due to hepatic rupture and hemorrhage, is one of the leading noninfectious idiopathic causes of mortality in backyard chickens. Nutritional, genetic, environmental, and hormonal factors, or combinations of these, have been proposed yet not proven as the underlying cause. In an attempt to characterize the hepatic changes leading to the syndrome, this retrospective case study examined 76 backyard chickens that were diagnosed with fatty liver hemorrhagic syndrome between January 2007 and September 2012 and presented for necropsy to the diagnostic laboratory of the California Animal Health and Food Safety Laboratory System. A majority of the birds were female (99%), obese (97.5%), and in active lay (69.7%). Livers were examined histologically, and the degree of hepatocellular vacuolation (lipidosis), the reticular stromal architecture, the presence of collagenous connective tissue, and vascular wall changes were evaluated and graded using hematoxylin and eosin, Gomori’s reticulin, oil red O, Masson’s trichrome, and Verhoeff-Van Gieson stains. Interestingly, there was no correlation between lipidosis and reticulin grades; hepatocellular lipidosis was absent in 22% of the cases and mild in 26% of the cases. Additionally, there was evidence of repeated bouts of intraparenchymal hemorrhage before the acute “bleed-out” in 35.5% of the cases. These data are not supportive of the previously proposed causes and provide a framework for future studies to elucidate the pathogenesis of this condition. Furthermore, the data shown in this study support hemorrhagic liver syndrome as a more accurate name, as hepatic lipidosis is absent in a significant proportion of ruptured livers.

Chronic infections of West Nile virus detected in California dead birds

During 2010 and 2011, 933 recently deceased birds, submitted as part of the dead bird surveillance program, tested positive for West Nile virus RNA at necropsy. The relative amount of RNA measured by qRT-PCR cycles ranged from 8.2 to 37.0 cycle threshold (Ct) and formed a bimodal frequency distribution, with maxima at 20 and 36 Ct and minima at 28-30 Ct. On the basis of frequency distributions among different avian species with different responses to infection following experimental inoculation, field serological data indicating survival of infection, and the discovery of persistent RNA in experimentally infected birds, dead birds collected in nature were scored as "recent" or "chronic" infections on the basis of Ct scores. The percentage of birds scored as having chronic infections was highest during late winter/spring, when all birds were after hatching year, and lowest during late summer, when enzootic transmission was typically highest as indicated by mosquito infections. Our data indicated that intervention efforts should not be based on dead birds with chronic infections unless supported by additional surveillance metrics.

Severe ulceronecrotic dermatitis associated with mite infestation in the critically endangered Amargosa vole (Microtus californicus scirpensis)

The entire range of the critically endangered Amargosa vole (Microtus californicus scirpensis) consists of less than 20 km(2) of riparian habitat in the Amargosa River drainage of the Mojave Desert in southern California. In September 2010, deformities on ears and chiggers on the ears and genitalia were detected, with some individuals so severely affected that they were missing ear pinnae altogether. Follow-up trapping was performed to document the presence of mites and mite-associated disease, and molecular characterization was performed on the mites. Of 151 Amargosa voles sampled from February to April of 2011, 60 (39.7%) voles had hard orange mites adhered to some part of their bodies, on ears of 46 (76.7%), on genitalia of 11 (18.3%), and near mammary tissue of 13 (21.7%) voles. Gross lesions were not detected on genitalia, but 47% of all individuals examined showed pinnal lesions and deformities, which included alopecia, swelling, marginal necrosis, and ulceration, as well as scarring, scabbing, and loss of pinna mass covering 25-100% of the pinnae. Biopsies revealed parakeratotic hyperkeratosis and acanthosis with diffuse neutrophilic exocytosis and dense necrotic granulocytes in the epidermis and superficial dermis associated with focal erosion and ulceration. In the underlying dermis, there were dense pleocellular inflammatory cell infiltrates composed primarily of necrotic granulocytes and multifocal hemorrhage. In some samples, mite mouthparts could be seen penetrating the superficial epidermis associated with focal necrosis, and mite fragments were found on the surface epidermis and within hair follicles. Microscopic examination of the mites documented that they were a larval trombiculid in the genus Neotrombicula with anatomical features that most closely resemble Neotrombicula microti, based on scutal shape, setation, and texture. PCR of 2 mite pools (each consisting of 3 mites from an individual animal) amplified 331 bp amplicons, which had 92-97% homology with the 18S rRNA gene of Leptotrombidium deliense, although coverage of Trombiculidae in GenBank is sparse. The severity and prevalence of lesions due to this chigger were atypical and distinct. Severe clinical trombiculiasis in this endangered species could negatively impact individual health and fitness.

Detection of persistent west nile virus RNA in experimentally and naturally infected avian hosts

To determine whether West Nile virus (WNV) persistent infection in avian hosts may potentially serve as an overwintering mechanism, House Sparrows and House Finches, experimentally and naturally infected with several strains of WNV, and two naturally infected Western Scrub-Jays were held in mosquito-proof outdoor aviaries from 2007-March 2008. Overall, 94% (n = 36) of House Sparrows, 100% (n = 14) of House Finches and 2 Western Scrub-Jays remained WNV antibody positive. When combined by species, 37% of the House Sparrows, 50% of the House Finches, and 2 Western Scrub-Jays were WNV RNA positive at necropsy, up to 36 weeks post-infection. Infectious WNV was not detected. Our study supports the hypothesis that some avian hosts support the long-term persistence of WNV RNA, but it remains unresolved whether these infections relapse to restart an avian-arthropod transmission cycle and thereby serve as an overwintering mechanism for WNV.

Pan-London tuberculosis services: a service evaluation

Background

London has the largest proportion of tuberculosis (TB) cases of any western European capital, with almost half of new cases drug-resistant. Prevalence varies considerably between and within boroughs with research suggesting inadequate control of TB transmission in London. Economic pressures may exacerbate the already considerable challenges for service organisation and delivery within this context. This paper presents selected findings from an evaluation of London’s TB services’ organisation, delivery, professional workforce and skill mix, intended to support development of a strategic framework for a pan-London TB service. These may also interest health service professionals and managers in TB services in the UK, other European cities and countries and in services currently delivered by multiple providers operating independently.

Methods

Objectives were: 1) To establish how London’s TB services are structured and delivered in relation to leadership, management, organisation and delivery, coordination, staffing and support; 2) To identify tools/models for calculating skill mix as a basis for identifying skill mix requirements in delivering TB services across London; 3) To inform a strategic framework for the delivery of a pan-London TB service, which may be applicable to other European cities. The multi-method service audit evaluation comprised documentary analysis, semi-structured interviews with TB service users (n = 10), lead TB health professionals and managers (n = 13) representing London’s five sectors and focus groups with TB nurses (n = 8) and non-London network professionals (n = 2).

Results

Findings showed TB services to be mainly hospital-based, with fewer community-based services. Documentary analysis and professionals’ interviews suggested difficulties with early access to services, low suspicion index amongst some GPs and restricted referral routes. Interviews indicated lack of managed accommodation for difficult to treat patients, professional workforce shortages, a need for strategic leadership, nurse-led clinics and structured career paths for TB nurses and few social care/outreach workers to support patients with complex needs.

Conclusions

This paper has identified key issues relating to London’s TB services’ organisation, delivery, professional workforce and skill mix. The majority of these present challenges which need to be addressed as part of the future development of a strategic framework for a pan-London TB service. More consistent strategic planning/co-ordination and sharing of best practice is needed, together with a review of pan-London TB workforce development strategy, encompassing changing professional roles, skills development needs and patient pathways. These findings may be relevant with the development of TB services in other European cities.

Acute respiratory distress in an alpaca

An alpaca was presented with a history of respiratory difficulty and death. Histology of the phrenic nerves and diaphragm revealed degenerative changes consistent with denervation atrophy, and a diagnosis of diaphragmatic paralysis was established. No gross or histological abnormalities were observed in the spinal cord or other organs. The etiology of the phrenic nerve neuropathy could not be determined. The need to examine phrenic nerves and diaphragm in camelids with respiratory distress is emphasized, as failure to examine these samples will preclude a diagnosis of diaphragmatic paralysis.

Novel amdovirus in gray foxes

We used viral metagenomics to identify a novel parvovirus in tissues of a gray fox (Urocyon cinereoargenteus). Nearly full genome characterization and phylogenetic analyses showed this parvovirus (provisionally named gray fox amdovirus) to be distantly related to Aleutian mink disease virus, representing the second viral species in the Amdovirus genus.

Disseminated pleomorphic myofibrosarcoma in a grizzly bear (Ursus arctos horribilis)

The pathological and diagnostic features of a widely disseminated pleomorphic high-grade myofibroblastic sarcoma are described in a 23-year-old male brown bear (Ursus arctos horribilis). Firm, solid, white to tan neoplastic nodules, often with cavitated or soft grey-red necrotic centres, were observed throughout most internal organs, subcutaneous tissues and skeletal muscles on gross examination. Microscopically, the tumour consisted of pleomorphic spindle cells forming interlacing fascicles with a focal storiform pattern with large numbers of bizarre polygonal multinucleate cells, frequently within a collagenous stroma. Immunohistochemistry, Masson's trichrome stain and transmission electron microscopy designated the myofibroblast as the cell of origin. This is the first case of a high-grade myofibrosarcoma in a grizzly bear.

Clostridium piliforme encephalitis in a weaver bird (Ploceus castaneiceps)

A juvenile Taveta golden weaver ( Ploceus castaneiceps) bird housed in a zoo aviary developed a sudden onset of neurological signs. The bird demonstrated head tilt, rolling onto its back, and inability to perch. Euthanasia was elected due to lack of response to intensive care, and a necropsy was performed. There were no significant abnormal findings on gross examination. On histopathology, the remarkable findings were localized to the brain and consisted of multifocal cerebral microabscesses and rarefaction. Filamentous rod-shaped bacteria were present within and at the periphery of the necrotic foci, and dispersed throughout the neuroparenchyma and intracellularly in neurons. The bacteria were Gram negative, and Warthin–Starry stain demonstrated characteristic “hay stacking.” Real-time polymerase chain reaction analysis of the brain identified the agent as Clostridium piliforme. An additional microscopic finding was severe crypt enteritis; however, the bacteria were not observed in the intestinal sections.

Pyogranulomatous pleuropneumonia and mediastinitis in ferrets (Mustela putorius furo) associated with Pseudomonas luteola Infection

Between 2008 and 2009, three pet ferrets from different sources presented with acute episode of dyspnoea. Cytological examination of pleural exudates revealed severe purulent inflammation with abundant clusters of rod-shaped microorganisms with a clear surrounding halo. Treatment was ineffective and the ferrets died 2–5 days later. Two ferrets were subjected to necropsy examination, which revealed pyothorax, mediastinal lymphadenopathy and multiple white nodules (1–2 mm) in the lungs. Microscopical examination showed multifocal necrotizing-pyogranulomatous pleuropneumonia and lymphadenitis with aggregates of encapsulated microorganisms, some of which were positively stained by periodic acid–Schiff and alcian blue. In-situ hybridization for Pneumocystis spp., Ziehl–Neelsen staining and immunohistochemistry for distemper, coronavirus and influenza antigen were negative in all cases. Electron microscopically, the bacteria were 2–3 μm long with a thick electron-lucent capsule. Microbiology from one ferret yielded a pure culture of gram-negative bacteria identified phenotypically as Pseudomonas luteola. This speciation was later confirmed by 16S RNA gene amplification.

Efficacy of three vaccines in protecting Western Scrub-Jays (Aphelocoma californica) from experimental infection with West Nile virus: implications for vaccination of Island Scrub-Jays (Aphelocoma insularis)

The devastating effect of West Nile virus (WNV) on the avifauna of North America has led zoo managers and conservationists to attempt to protect vulnerable species through vaccination. The Island Scrub-Jay (Aphelocoma insularis) is one such species, being a corvid with a highly restricted insular range. Herein, we used congeneric Western Scrub-Jays (Aphelocoma californica) to test the efficacy of three WNV vaccines in protecting jays from an experimental challenge with WNV: (1) the Fort Dodge West Nile-Innovator(®) DNA equine vaccine, (2) an experimental DNA plasmid vaccine, pCBWN, and (3) the Merial Recombitek(®) equine vaccine. Vaccine efficacy after challenge was compared with naïve and nonvaccinated positive controls and a group of naturally immune jays. Overall, vaccination lowered peak viremia compared with nonvaccinated positive controls, but some WNV-related pathology persisted and the viremia was sufficient to possibly infect susceptible vector mosquitoes. The Fort Dodge West Nile-Innovator DNA equine vaccine and the pCBWN vaccine provided humoral immune priming and limited side effects. Five of the six birds vaccinated with the Merial Recombitek vaccine, including a vaccinated, non-WNV challenged control, developed extensive necrotic lesions in the pectoral muscle at the vaccine inoculation sites, which were attributed to the Merial vaccine. In light of the well-documented devastating effects of high morbidity and mortality associated with WNV infection in corvids, vaccination of Island Scrub-Jays with either the Fort Dodge West Nile-Innovator DNA vaccine or the pCBWN vaccine may increase the numbers of birds that would survive an epizootic should WNV become established on Santa Cruz Island.

Phase Ib study of mapatumumab in combination with sorafenib in patients with advanced hepatocellular carcinoma (HCC) and chronic viral hepatitis

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Background: Mapatumumab is a fully human agonist monoclonal antibody to the tumor necrosis factor-related apoptosis-inducing ligand receptor 1 (TRAIL-R1). Sorafenib targets Mcl-1, a key TRAIL resistance protein, and accordingly could enhance mapatumumab's pro-apoptotic activity. Based on this and on preclinical data on mapatumumab in HCC cell lines, the current dose-escalation study is evaluating mapatumumab in combination with sorafenib in patients with advanced HCC.

Methods: Eligible patients had advanced HCC, Child-Pugh A or Model for End-Stage Liver Disease score < 15, and were positive for hepatitis B surface antigen or hepatitis C antibody. Intravenous mapatumumab was administered at 3, 10 or 30 mg/kg every 21 days with sorafenib (400 mg twice daily) until disease progression or unacceptable toxicity. Dose-limiting toxicities (DLTs) included events considered at least possibly related to mapatumumab and/or its interaction with sorafenib. Tumor measurements were performed every 2 cycles. Dose escalation required at least 3 patients in a cohort to receive >= 50% of full-dose sorafenib in the first 2 cycles.

Results: To date, 19 patients have been enrolled in the 3 mg/kg (n=6), 10 mg/kg (n=9) and 30 mg/kg (n=4) cohorts and have received a median of 4 cycles (range 1 to 24 cycles); 4 patients have received >= 11 cycles. The maximum tolerated dose has not been reached. DLTs that prompted expansion of the 3 mg/kg and 10 mg/kg cohorts were elevations of amylase and/or lipase (1 at 3 mg/kg, 1 at 10 mg/kg). Other Grade 3-4 events considered at least possibly related to mapatumumab and/or its interaction with sorafenib included hepatic pain (1/17), thrombocytopenia (1/17), increased aspartate aminotransferase (1/17), increased lipase (1/17), and increased gamma-glutamyltransferase (1/17). Two patients have had a partial response and 4 patients have had stable disease lasting > 12 weeks, based on investigator assessment.

Conclusions: Mapatumumab was well-tolerated at doses up to 30 mg/kg in combination with sorafenib in patients with HCC and viral hepatitis. A randomized phase II study of this combination in patients with advanced HCC is planned.

[Table: see text]

Listening to those on the frontline: service users' experiences of London tuberculosis services

AIM

To explore tuberculosis (TB) service users' experiences and satisfaction with care provision.

BACKGROUND

Thirty-nine percent of all new UK TB cases occur in London. Prevalence varies considerably between and within boroughs. Overall, research suggests inadequate control of London's TB transmission; TB has become a health care priority for all London Primary Care Trusts. Service users' experiences and satisfaction with care provision have not been explored adequately previously.

METHODS

A qualitative research design, using semi-structured face-to-face interviews was used. Ten service users, purposively selected in key risk groups across London, were interviewed. All interviews were digitally recorded with users' permission, transcribed verbatim, and analyzed thematically.

RESULTS

Participants were treated in local hospitals for 6-12 months. Treatment was administered by TB nurses to inpatients and outpatients receiving directly observed therapy in consultation with medical staff and home visits for complex cases. Two participants did not realize the importance of compliance. Overall, they were satisfied with many TB services' aspects, communication, and service organization. Early access, low suspicion index amongst some GPs, and restricted referral routes were identified as service barriers. Other improvement areas were information provision on drug side effects, diet, nutritional status, and a few health professionals' attitudes. The effects on people varied enormously from minimal impact to psychological shock; TB also affected social and personal aspects of their life. With regard to further support facilities, some positive views on managed accommodation by TB-aware professionals for those with accommodation problems were identified.

CONCLUSION

This first in-depth study of TB service users' experiences across London offers valuable insights into service users' experiences, providing information and recommendations for a strategic framework for TB service organization and delivery. Overall, further research is needed; TB services - local, national, and international - need to be more closely aligned with service users' complex needs.

Pharmacokinetics of voriconazole in adult mallard ducks (Anas platyrhynchos)

The pharmacokinetics of voriconazole (VRC) administered intravenously (IV) or orally (PO; with and without liquid diet) to mallard ducks were studied. Dose range, drug bioavailability, and single and multiple treatment pharmacokinetics studies were performed. Plasma samples were collected for ultra performance liquid chromatography (UPLC) or bioassay analysis. Tissue samples were collected for high performance liquid chromatography (HPLC) analysis and histology. No overt signs of toxicity were observed during any of the studies regardless of administration route, and no histologic lesions/changes were attributed to VRC treatment. Average ± SD bioavailability after a single oral dose was 60.7% ± 16.5. Based on a targeted minimum inhibitory concentration of 0.5 μg/ml VRC, a dose of 20 mg per kg body weight for the multi-dose pharmacokinetic study was selected. Pharmacokinetic parameter differences between birds dosed with VRC, with or without liquid diet, were not clinically significant. The bioassay had an overall positive bias (+23.5%) compared to the UPLC. Single or multiple-day VRC dosing via IV or PO routes at differing dosages resulted in tissue concentrations that were below the HPLC assay's limit of detection (0.1 μg VRC per g tissue). This study indicates that treatment of mallard ducks with VRC might require a dosing interval of at least every 8-12 h at a dose of 20 mg/kg, but further studies are necessary.

Pathology and immunohistochemical findings of west nile virus infection in psittaciformes

West Nile virus (WNV) infection was diagnosed in 38 psittacine birds based on histology, immunohistochemistry, and reverse transcriptase polymerase chain reaction (RT-PCR). Rosellas (Platycercus spp, n = 13), conures (Enicognathus, Aratinga, and Nandayus spp, n = 6), and lorikeets (Trichoglossus spp, n = 6) represented the most commonly affected species. Clinical signs ranged from lethargy, ruffled feathers, anorexia, and weight loss in most birds to sudden death in others. Except for mild to moderate enlargement of liver and spleen, there were no significant gross lesions at necropsy. Histopathologic findings included lymphoplasmacytic and histiocytic hepatitis, interstitial nephritis, myocarditis, splenitis, enteritis, pancreatitis, and occasionally, encephalitis. Viral antigen was detected by immunohistochemistry in 34 of 35 hearts (97.1%), 29 of 32 pancreata (90.6%), 33 of 37 kidneys (89.2%), 31 of 35 intestines (88.6%), 27 of 33 gizzards (81.8%), 8 of 10 ovaries (80%), 27 of 34 spleens (79.4%), 30 of 38 livers (78.9%), 23 of 32 lungs (71.9%), 21 of 31 proventriculi (67.7%), 14 of 21 adrenals (66.7%), 10 of 16 testes (62.5%), 17 of 30 brains (56.7%), 15 of 27 skins (55.5%), 3 of 6 oviducts (50%), 15 of 34 skeletal muscles (44.1%), 11 of 27 crop or esophagus (40.7%), and 1 of 6 thymuses (16.7%). Kidney was positive for WNV by RT-PCR in all the cases tested. In conclusion, Psittaciformes are susceptible to West Nile virus infection, and WNV infections are often associated with nonspecific clinical signs and widespread viral distribution in this order of birds.

Specialist nursing interventions for inflammatory bowel disease

BACKGROUND

The number, type and roles of specialist nurses dedicated to the care and management of patients with inflammatory bowel disease is increasing. Despite this increase, there has been little evidence to date to demonstrate the effectiveness of specialist nursing interventions. This review aims to identify and evaluate the impact of specialist nursing interventions on management of inflammatory bowel disease, access to treatment, remission, morbidity and quality of life.

OBJECTIVES

To identify and evaluate the impact of specialist nursing interventions for improving the care and management of patients with inflammatory bowel disease (IBD).

SEARCH STRATEGY

A comprehensive search of databases including the Cochrane Library, MEDLINE, and British Nursing Index was carried out to identify trials. References from relevant papers were searched and hand searching was undertaken of relevant publications including gastroenterology conference proceedings to identify additional trials (date of last search 30 September 2008).

SELECTION CRITERIA

Randomised controlled trials, controlled before and after studies and interrupted time series studies of gastroenterology and IBD specialist nurses intending to improve access and outcomes for patients with ulcerative colitis and Crohn's disease were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two investigators independently extracted data and assessed trial quality. Any discrepancies were resolved by consensus.

MAIN RESULTS

One randomised controlled trial of 100 IBD patients receiving a specialist nurse delivered counselling package (n = 50) or routine outpatient clinic follow-up (n = 50), with assessments at entry and six and 12 months, was included in this review. This study was of low methodological quality. Disease remission, patient compliance, clinical improvement, utilisation of nurse-led services, patient satisfaction, hospital admission, outpatient attendance, progression to surgery, length of hospital stay and cost effectiveness data were not reported. Pooled mean mental health scores at 6 months were higher in patients who received nurse-led counselling compared to patients who received routine follow-up. However, this difference was not statistically significant (WMD 3.67; 95% CI -0.44 to 7.77; P = 0.08). Other pooled assessments of physical and psychological well-being showed no statistically significant differences.

AUTHORS' CONCLUSIONS

Although specialist nurse counselling interventions might provide benefit for IBD patients the one included study was of low quality and the results of this study should be interpreted with caution. Higher quality trials of gastroenterology and IBD specialist nursing interventions are needed to assess the impact of specialist nursing interventions on the care and management of patients with inflammatory bowel disease.

Efficacy of voriconazole in Japanese quail (Coturnix japonica) experimentally infected with Aspergillus fumigatus

Aspergillus fumigatus causes disease in birds. Our objectives were to determine pharmacokinetic parameters and evaluate efficacy of voriconazole (VCZ) in a novel experimental quail model. After a single oral VCZ dose of 20 or 40 mg/kg, plasma concentrations peaked 2 h postdose (5.8 and 6.9 microg/ml) and remained above 0.5 microg/ml for 4 and 12 h postdose, respectively. For the efficacy study, ten-day-old Japanese quail (n = 60) were infected intratracheally with A. fumigatus conidia. Daily oral VCZ at 20 or 40 mg/kg was initiated 24 h postinfection (PI); infected diluent-treated birds were given de-ionized water orally. Preassigned birds were euthanized on days 5 or 10 PI. VCZ at 40 mg/kg prolonged survival compared to 20 mg/kg or diluent-treatment (P < 0.05) and lungs from birds given VCZ at 40 mg/kg had fewer colony forming units (CFU) than diluent-treated (P = 0.03). At day 10 PI, birds treated with VCZ at 20 mg/kg had significantly fewer fungi in the lungs as demonstrated by methenamine silver stain (P = 0.017) or immunohistochemistry, as compared to diluent-treated (P = 0.034). Histopathologically, VCZ-treated birds did not have necrotic lesions and showed a trend toward fewer with acute inflammatory changes. VCZ at 40 mg/kg was efficacious in quail with experimental pulmonary aspergillosis.

Implementing a strategy to promote lifelong learning in the primary care workforce: an evaluation of leadership roles, change management approaches, interim challenges and achievements

OBJECTIVES

To identify and explore leadership roles and responsibilities for implementing the workforce development strategy; to identify approaches used to implement and disseminate the strategy; and to identify and explore challenges and achievements in the first 18 months following implementation.

DESIGN

A formative evaluation with qualitative methods was used. Documentary analysis, interviews (n = 29) and two focus groups (n = 12) were conducted with a purposive sample of individuals responsible for strategy implementation. Data were transcribed and analysed thematically using framework analysis.

SETTING

Regional health area in Kent, Surrey and Sussex: 24 primary care trusts (PCTs) and 900 general practices.

RESULTS

Primary care workforce tutors, lifelong learning advisors, GP tutors, patch associate GP deans and chairs of PCT education committees all had vital leadership roles, some existing and others newly developed. Approaches used to implement the strategy encompassed working within and across organisational boundaries, communication and dissemination of information. Challenges encountered by implementers were resistance to change - evident in some negative attitudes to uptake of training and development opportunities - and role diversity and influence. Achievements included successes in embedding appraisal and protected learning time, and changes in educational practices and services.

CONCLUSIONS

The use of key leadership roles and change-management approaches had brought about early indications of positive transition in lifelong learning cultures.

An open label safety and efficacy phase 2a study of the N-cadherin (N-cad) antagonist ADH-1 in subjects with N-cadherin expressing solid tumors

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Background: Malignant transformation and invasive capacity is highly correlated with N-cad, a cell adhesion molecule expressed on tumor cells and vascular endothelium. ADH-1, a cyclic pentapeptide (CHAVC), is a functional inhibitor of N-cad, and produces apoptosis and tumor vascular disruption in preclinical models. We report results from a Phase 2a study of intravenous (IV) ADH-1 (q 3 W, modified to qW) in subjects with N-cad+ solid tumors. Methods: Subjects with the following N-cad+ refractory tumors with measurable disease were eligible: renal cell (RCC); hepatocellular (HCC); adrenocortical (ACC); gastroesophageal (GE); NSCLC; HNSCC; and breast (HSNCC and breast subjects were only eligible for q3W schedule). ADH-1 was administered at 500 mg/m2 q 3 W, or 600 mg/m2 in the qW schedule. Intra-subject dose escalation was permitted at cycle 3 to 600 mg/m2 (900 mg/m2 with the qW schedule) in the absence of significant toxicity, tumor response or progression. Results: Tumor samples from 159 subjects were tested for N-cad, and 90 were N-cad+ (N-cad+/number tested: GE 13/48, HCC 29/35; NSCLC 16/33; RCC 27/28; ACC 3/8; HNSCC 2/6; Breast 0/1). Forty subjects, 10 on the q3W and 30 on the qW schedule (19 HCC; 7 RCC; 6 NSCLC; 6 GE; 1 ACC; 1 HNSCC) received 121 cycles of ADH-1. The drug was well tolerated, with commonly reported adverse events being Grade 1 or 2 in severity. One subject with HCC had pre-existing renal insufficiency, developed Grade 2 nausea and vomiting 11 days after the 3rd cycle of ADH-1 administered q 3W, leading to non-oliguric renal failure. Following an initial period of recovery, she developed sepsis and died; these events were considered to not be related to study drug. A second subject with HCC developed a hemiparesis due to a Grade 3 intracranial hemorrhage from a previously unknown metastatic brain lesion, 5 days after the 1st dose of ADH-1. There were no complete or partial responses; 32 subjects had SD for =2 cycles, 8 had SD for =4 cycles (4 HCC, ACC, GE, RCC, HNSCC), 6 had SD for =6 cycles (3 HCC, GE, RCC, HNSCC). The longest duration on study was 12 cycles (RCC). Conclusions: ADH-1 was well tolerated and prolonged SD was noted in several subjects.

No significant financial relationships to disclose.

West Nile virus infection in tree squirrels (Rodentia: Sciuridae) in California, 2004-2005

West Nile virus (WNV) transmission generally involves a mosquito vector and an avian reservoir host, with mammals as incidental hosts. Although most mammalian WNV infections cause low or no morbidity or mortality, tree squirrels are susceptible to WNV-associated neurologic disease with infection prevalence comparable to that in dead birds. Positive species included fox squirrel (Sciurus niger), western gray squirrel (S. griseus), and eastern gray squirrel (S. carolinensis). Kidney tissue (dissected and swabbed), and oropharyngeal (oral) swab samples from tree squirrels submitted by California vector control and rehabilitation agencies were tested by reverse transcription-polymerase chain reaction; cycle threshold values were similar for all three samples, ranging from 21.9 to 26.5. Kidney tissue was more sensitive than oral swabs for detecting WNV in squirrels. Three of 36 live neurologic tree squirrels had viremia approximately 5 log(10) plaque-forming units/mL or greater, similar to WNV-infected birds. Tree squirrels are useful in WNV surveillance and provide localized evidence of WNV transmission to mammals.

Field and Laboratory Evaluation of Diagnostic Assays for Detecting West Nile Virus in Oropharyngeal Swabs from California Wild Birds

Three diagnostic assays for detecting West Nile virus (WNV) in avian oral swabs were evaluated in California in 2004 and 2005: two commercial antigen-capture assays, VecTest and Rapid Analyte Measurement Platform (RAMP), and reverse transcriptase-polymerase chain reaction (RT-PCR) of oral swabs in a specialized viral transport medium (VTM). Results from this study demonstrated that VTM was excellent for transportation and maintenance of WNV in avian oral swab samples and allowed for detection by RT-PCR and subsequent confirmation by virus isolation. Oral swabs and kidney tissue in VTM tested by RT-PCR were found to have similar accuracy in detecting WNV in corvids. The two antigen-capture assays, VecTest and RAMP, provided few false positives for corvids, with over 95% specificity. When performed by multiple local agencies throughout the state, VecTest and RAMP were similarly sensitive for oral swabs of American Crows (Corvus brachyrhynchos) (70% and 64%, respectively). Data from known WNV positive corvid oral swabs in VTM tested by antigen-capture assays at a diagnostic laboratory suggested that RAMP was more sensitive than VecTest. Due to high probability of false negatives, neither test is recommended for use on non-corvids. While WNV antigen-capture assays were effective screening tools for corvids, they were markedly less sensitive for Western Scrub Jays (Aphelocoma californica).

Evaluating the clinical effectiveness of neonatal nurse practitioners: an exploratory study

AIM AND OBJECTIVES

The aim of the investigation was to establish if there was any preliminary evidence to indicate if the quality of care and clinical outcomes for premature birth babies are affected by the type of practitioner (i.e. nurse practitioner vs. medical practitioner) responsible for the initial assessment, treatment and management of neonates during the first 6-12 hours following admission to a neonatal intensive care unit.

BACKGROUND

The United Kingdom (UK) has seen a proliferation in the number of nurse practitioners in the past decade. While there is a growing body of evidence to suggest that nurse practitioners in primary care settings are able to provide a high quality and effective level of clinical service comparable with many of their medical counterparts, there has been relatively little evaluation of the nurse practitioner role in acute or high dependency hospital settings.

DESIGN AND METHODS

The study design used a mixed method approach combining a retrospective examination and quality assessment of nursing and medical records. A random sample of 61 sets of medical records, relating specifically to the initial management and treatment of neonates were criterion assessed by an experienced consultant neonatologist and a variety of patient outcome data collated and analysed.

RESULTS

The analysis of the patient outcome data and quality assessment of nursing and medical records revealed that there was no statistical difference in the standard and quality of care provided between nurse practitioners and medical staff in the vast majority of areas evaluated. However, trends in the data suggest that Advanced Neonatal Nurse Practitioners (ANNPs) did not perform as well as their medical counterparts in terms of the overall completeness or comprehensiveness of the standard care provided in a number of areas.

CONCLUSION

Neonatal nurse practitioners provide an alternative model of service delivery in the initial admission and management of premature birth babies. While the results of the study suggest that ANNPs do not perform as well as medical staff, in the majority of cases, they still performed to an acceptable standard. Nonetheless, some deficits in the standard of care provided by both groups of practitioners were identified which in turn have implications for ongoing training and skills development. Relevance to clinical practice. The findings suggest that ANNPs are capable of taking on an advanced role in the assessment and management of neonates.