Development and acceptability of a culturally competent skills and knowledge assessment tool for patients with diabetes mellitus

Background

Patients newly diagnosed with type 2 diabetes mellitus (DM) and newly prescribed insulin need to learn essential self-care and management skills quickly. To optimize teaching, clinicians need to assess a patient's basic understanding of DM and their skills. While DM patient assessments exist, this study reports the development of an assessment of patient DM management skills and knowledge, using feedback from DM clinicians, patients, and caregivers.

Research Design and Methods

A systematic search of Pubmed/Medline and Scopus (1980-2017) of DM knowledge assessments was performed. Twenty-four studies were identified. Content from the existing assessments was adapted to create a 12 item DM-Skills Knowledge Assessment (SKA) to assess a patient's DM management skills and knowledge. To assess cultural humility, modified cognitive interviews were conducted in individual user sessions and semi-structured focus groups. Audio-transcripts of the interviews/focus groups were independently coded, and codes were grouped into key themes. Participant demographic characteristics were assessed.

Results

Five focus groups and eleven key informant interviews were conducted, including 10 DM clinicians, 12 patients/caregivers, and 15 laypersons. All 10 clinicians reported that the DM-SKA addresses the key domains of DM education deemed to be of highest importance during the transition from hospital to home and that their patients would be willing to complete the assessment. More than half of the patient/caregiver/layperson participants self-reported race/ethnicity other than non-Hispanic white and performed similarly to non-Hispanic white participants in understanding each item, willingness to complete the DM-SKA, and perception that family or community members would be willing to complete the DM-SKA. The DM-SKA has a baseline Flesch reading score of 81.3, indicating low complexity language.

Conclusion

DM clinicians agreed that the DM-SKA assesses all essential DM management skills. For patients/caregivers, it has acceptable literacy, cognitive validity, and culturally acceptable for racial/ethnic minority populations in the study, including elderly persons.

Association of Metformin With the Development of Age-Related Macular Degeneration

Importance

Age-related macular degeneration (AMD) is a leading cause of blindness with no treatment available for early stages. Retrospective studies have shown an association between metformin and reduced risk of AMD.

Objective

To investigate the association between metformin use and age-related macular degeneration (AMD).

Design, Setting, and Participants

The Diabetes Prevention Program Outcomes Study is a cross-sectional follow-up phase of a large multicenter randomized clinical trial, Diabetes Prevention Program (1996-2001), to investigate the association of treatment with metformin or an intensive lifestyle modification vs placebo with preventing the onset of type 2 diabetes in a population at high risk for developing diabetes. Participants with retinal imaging at a follow-up visit 16 years posttrial (2017-2019) were included. Analysis took place between October 2019 and May 2022.

Interventions

Participants were randomly distributed between 3 interventional arms: lifestyle, metformin, and placebo.

Main Outcomes and Measures

Prevalence of AMD in the treatment arms.

Results

Of 1592 participants, 514 (32.3%) were in the lifestyle arm, 549 (34.5%) were in the metformin arm, and 529 (33.2%) were in the placebo arm. All 3 arms were balanced for baseline characteristics including age (mean [SD] age at randomization, 49 [9] years), sex (1128 [71%] male), race and ethnicity (784 [49%] White), smoking habits, body mass index, and education level. AMD was identified in 479 participants (30.1%); 229 (14.4%) had early AMD, 218 (13.7%) had intermediate AMD, and 32 (2.0%) had advanced AMD. There was no significant difference in the presence of AMD between the 3 groups: 152 (29.6%) in the lifestyle arm, 165 (30.2%) in the metformin arm, and 162 (30.7%) in the placebo arm. There was also no difference in the distribution of early, intermediate, and advanced AMD between the intervention groups. Mean duration of metformin use was similar for those with and without AMD (mean [SD], 8.0 [9.3] vs 8.5 [9.3] years; P = .69). In the multivariate models, history of smoking was associated with increased risks of AMD (odds ratio, 1.30; 95% CI, 1.05-1.61; P = .02).

Conclusions and Relevance

These data suggest neither metformin nor lifestyle changes initiated for diabetes prevention were associated with the risk of any AMD, with similar results for AMD severity. Duration of metformin use was also not associated with AMD. This analysis does not address the association of metformin with incidence or progression of AMD.

POS0377 ONE YEAR OF DIGITAL HEALTH APPLICATIONS (DiGA) IN GERMANY – RHEUMATOLOGISTS’ PERSPECTIVES

Background

Based on given legislation (§§ 33a and 139e SGB V, Social Code Book V) the German approach to digital health applications (Digitale Gesundheitsanwendungen, DiGA) allows reimbursed prescription of approved therapeutic software products (listed in the DIGA directory https://diga.bfarm.de/de/verzeichnis) for patients since October 6th, 2020.

Objectives

To evaluate the level of knowledge on DiGA among members of the German Society for Rheumatology (DGRh) after one year of DiGA under the conditions of the COVID-19 pandemic using the DiGA Toolbox of the ‘health innovation hub’ (hih), a think tank and sparrings partner of the German Federal Ministry of Health.

Methods

Anonymous cross-sectional online survey using LimeSurvey (https://limesurvey.org). The survey was promoted by newsletters sent out to DGRh newsletter recipients and Twitter posts. Ethical approval was obtained.

Results

75 valid participants reported that they care more than 80% of their working time for patients with rheumatic diseases. Most were working in outpatient clinics (54%) and older than 40 years of age (84%). Gender distribution was balanced (50%).

70% were aware of the possibility to prescribe DiGA. Most were informed on this for the first time via trade press (63%), and only 8% via the professional society. 46% expect information on DiGA from professional societies and the medical chambers (36%) but rarely from the manufacturer (10%) and the responsible ministry (4%). Respondents would like to be informed about DIGA via continuing education events (face-to-face 76%, online 84%), trade press (86%), and manufacturers test accounts (64%).

Only 7% have already prescribed a DiGA, 46% planned to do so, and 47% did not intend DiGA prescriptions. Relevant aspects for prescription are given in Figure 1.

Figure 1.

Aspects relevant for DiGA prescriptions; sorted by importance/number of mentions (participants needed to pick their three most relevant aspects from a pre-given list)

86% believe that using DiGA / medical apps would at least partially be feasible and understandable to their patients.

83% thought that data collected by the patients using DiGA or other digital solutions could at least partially influence health care positively.

51% appreciated to get DiGA data directly into their patient documentation system resp. clinical electronic health record (EHR) and 29% into patients’ owned EHR.

Conclusion

DiGA awareness was high whereas prescription rate was low. Mostly, physician-desired aspects for DiGA prescriptions were proven efficacy and efficiency for physicians and patients, risk of adverse effects and health care costs were less important. Evaluation of patients’ barriers and needs are warranted. Our results will contribute to the implementation and dissemination of DIGA.

Disclosure of Interests

Jutta G. Richter: None declared, Gamal Chehab: None declared, Philipp Stachwitz: None declared, Julia Hagen: None declared, Denitza Larsen: None declared, Johannes Knitza Consultant of: Vila Health, ABATON, Medac, Matthias Schneider: None declared, Anna Voormann: None declared, Christof Specker: None declared

MON-139 Development of a Culturally Competent Skills and Knowledge Assessment Tool for Patients with Diabetes

Training of diabetes (DM) skills is critical to assure competency of DM survival skills (e.g. glucose testing) for immediate self-care. While DM assessments exist, we sought to develop a culturally acceptable DM Skills and Knowledge Assessment (DM-SKA) tool. A systematic search of Pubmed/Medline and Scopus (1980-2017) of assessments for DM knowledge was performed. 24 studies were identified, only 33% reported minority populations. Studies were classified by topic: measurement of DM skills, objectives of DM training, assessments of DM education, and other non-patient assessments. Content from existing assessments was adapted to create a 12 question DM-SKA to address 6 domains: DM, blood glucose and self-monitoring, support services, identification management of hypo and hyperglycemia, and insulin administration. To assess cultural acceptance, cognitive evaluations were conducted in individual user sessions and focus groups. The DM-SKA had a baseline Flesch reading score of 81.3 (low complexity language) and Flesch-Kincaid reading grade level of 5.3. Of 39 approached, 85% (N=33) participated (6 inpatients refused, feeling “overwhelmed”). Participants were diverse, including 8 clinicians, 10 patients/caregivers, and 15 laypersons; 46% were non-Hispanic whites, 33% non-Hispanic blacks, 12% Hispanics, and 9% Asian Americans. Mean age of patient/caregiver/laypersons was 57.8±17 (44% > age 65) and 40.1±12 years for clinicians (12.5% > age 65). All clinicians reported that appropriate DM skill domains were included and felt patients would complete the tool. All patients/caregivers and laypersons (N=25) verbalized adequate comprehension of each question; 96% reported willingness to complete the DM-SKA if provided and 88% reported their family, friends or someone in their community would be willing to complete it. However, both providers (N=2) and patients (N=2) reported concerns about assessment format and delivery [e.g. “testing” or “quiz”]. Some younger (<65 years) patients/caregiver/laypersons (N= 4) reported concerns about potential willingness of elderly family members to complete the tool. However, acceptability of the DM-SKA was noted from all participants >65 years. Vision problems and older age were identified as potential barriers. Of those offered the assessment (N = 25), 5 (20%) participants needed assistance [N=2 vision, N=3 English as second language]. Mean DM-SKA score was 10.2±1.7 of 12. Incorrect answers mostly occurred for questions with multiple correct answers. The DM-SKA has acceptable literacy characteristics, cognitive validity, and cultural acceptability by racial/ethnic minority populations, including elderly persons. Future work includes integration into clinical workflows and incorporation of patient preferences.

Efficacy of two formulations of afoxolaner (NexGard® and NexGard Spectra®) for the treatment of generalised demodicosis in dogs, in veterinary dermatology referral centers in Europe

Background

A multi-centre field trial was conducted to evaluate the efficacy of afoxolaner based chewables (NexGard® or NexGard Spectra®) for the treatment of generalised demodicosis caused by Demodex canis in dogs under field conditions in France, Italy and Poland.

Methods

Client-owned dogs, diagnosed positive for Demodex mites by pre-treatment skin scrapings and presenting clinical signs of generalised demodicosis were included. Dogs were orally treated with afoxolaner three times at monthly intervals. Of the 50 dogs enrolled, 48 completed the whole study. Efficacy of the treatments was assessed monthly by Demodex mite counts and physical examination with special regard to the severity and extension of skin lesions.

Results

Treatments were well tolerated in all dogs and resulted in a rapid reduction of mites, with all post-treatment mite counts significantly lower than baseline. The number of mites was reduced by 87.6%, 96.5% and 98.1% on Days 28, 56 and 84, respectively. In addition, the skin lesion severity and extent scores as well as the pruritus were all significantly lower at all post-treatment visits compared to the pre-treatment assessment.

Conclusions

This clinical field study demonstrated that monthly administrations of afoxolaner in NexGard® or NexGard Spectra®, offered a convenient and reliable solution for the treatment of canine generalised demodicosis.

The Small Acceptance Vertex Detector of NA61/SHINE

Charmonium production in heavy ion collisions is considered as an important diagnostic probe for studying the phase diagram of strongly interacting matter for potential phase transitions. The interpretation of existing data from the CERN SPS is hampered by a lack of knowledge on the properties of open charm particle production in the fireball. Moreover, open charm production in heavy ion collisions by itself is poorly understood. To overcome this obstacle, the NA61/SHINE was equipped with a Small Acceptance Vertex Detector (SAVD), which is predicted to make the experiment sensitive to open charm mesons produced in A-A collisions at the SPS top energy. This paper will introduce the concept and the hardware of the SAVD. Moreover, first running experience as obtained in a commissioning run with a 150 AGeV/c Pb+Pb collision system will be reported.

The Small Acceptance Vertex Detector of NA61/SHINE

Charmonium production in heavy ion collisions is considered as an important diagnostic probe for studying the phase diagram of strongly interacting matter for potential phase transitions. The interpretation of existing data from the CERN SPS is hampered by a lack of knowledge on the properties of open charm particle production in the fireball. Moreover, open charm production in heavy ion collisions by itself is poorly understood. To overcome this obstacle, the NA61/SHINE was equipped with a Small Acceptance Vertex Detector (SAVD), which is predicted to make the experiment sensitive to open charm mesons produced in A-A collisions at the SPS top energy. This paper will introduce the concept and the hardware of the SAVD. Moreover, first running experience as obtained in a commissioning run with a 150 AGeV/c Pb+Pb collision system will be reported.

Assessment of the insecticidal activity of afoxolaner against Aedes aegypti in dogs treated with NexGard®

Twelve healthy dogs were studied in this parallel group, blinded, randomised, and negative controlled efficacy study. On Day -1, the 12 dogs included were ranked within sex in descending order of individual pre-treatment (Day -5) fed mosquito counts and randomly allocated by blocks of two dogs to the untreated control group or the afoxolaner-treated group. NexGard^® (Merial, now part of Boehringer Ingelheim Animal Health) was administered orally on Day 0 in accordance with the European label instructions. On Days 1, 7, 14, 21 and 28, all dogs were exposed for a duration of 1 hour to 50 ± 5 unfed Aedes aegypti females. After each exposure, mosquitoes were collected after 1 hour and assessed for viability during collection and at 24 ± 2 hours. The arithmetic (and geometric) mean values of live fed mosquito counts at 24 hours after the exposure periods for the negative control group ranged from 33.7 (32.3) to 49.8 (49.7), indicating that this was a vigorous mosquito strain. There was no significant difference between control and treated groups in the number of live and fed mosquitoes at each 1 hour post-exposure collection time. Based on arithmetic and geometric mean values at 24 hours after each exposure, significantly fewer live fed mosquitoes were recorded in the treated group, compared to the negative control group, throughout the study (p < 0.001). The afoxolaner insecticidal efficacy against A. aegypti varied from 98% (Day 2) to 75.3% (Day 29) based on arithmetic means, and 98.7% (Day 2) to 89.8% (Day 29) based on geometric means.

Preventive efficacy of NexGard Spectra® against Dipylidium caninum infection in dogs using a natural flea (Ctenocephalides felis) infestation model

The efficacy of a monthly oral endectocide product, NexGard Spectra^® (Merial), a combination of afoxolaner and milbemycin oxime, was evaluated in a flea (Ctenocephalides felis) challenge model for the prevention of Dipylidium caninum tapeworm infection in dogs. The efficacy of treatment with NexGard Spectra^® was assessed in 10 dogs following weekly flea infestation with metacestode naturally infected fleas and compared with that in 10 untreated control dogs. The 100 fleas deposited weekly on each dog were not removed until Day 35, allowing enough time for their ingestion. The microscopical analysis of 30 fleas from the flea batches before each weekly challenge demonstrated that 10-33% of the fleas were infected by D. caninum cysticercoid larvae. The arithmetic mean flea count recorded was 47.7 for the 10 untreated dogs and 0 for the 10 treated dogs at Day 35. Based on the daily collection of expelled D. caninum proglottids by dogs during the 70 days of the study, 70% (7/10) of the control dogs and 0% (0/10) of the treated dogs were infected with D. caninum (p < 0.0031). Through its efficacy against fleas, NexGard Spectra^® treatment provided indirect prevention of D. caninum infestation. No treatment-related adverse events were observed in dogs during this study.

Efficacy of afoxolaner plus milbemycin oxime chewable tablets (NexGard Spectra®, Merial) against adult Ancylostoma ceylanicum hookworm, in dogs

A fixed-combination chewable tablet incorporating afoxolaner plus milbemycin oxime (NexGard Spectra^®, Merial) was tested in purpose-bred Beagle dogs for efficacy against adult Ancylostoma ceylanicum hookworms. Sixteen dogs were inoculated each by oral administration of approximately 500 infective larvae of A. ceylanicum. Seventeen days after inoculation, the dogs were weighed and allocated randomly to be treated with afoxolaner plus milbemycin oxime chewable tablets or to remain untreated. Commercial chewable tablets of different strength were combined to deliver doses as close as possible to the minimum effective dose of 2.5mg afoxolaner plus 0.5mg milbemycin oxime per kg body weight. Parasites were recovered and counted for determination of efficacy seven days after treatment. All eight dogs that had been left untreated were harboring adult A. ceylanicum (geometric mean, 317.8; range, 210-428) while only one and nine A. ceylanicum were recovered from two of the eight dogs treated with afoxolaner plus milbemycin oxime chewable tablets (geometric mean, 0.5; p<0.0001). Thus, 99.9% efficacy against induced infection of A. ceylanicum was obtained by the use of oral NexGard Spectra^® at the minimum effective dose. Treatment with afoxolaner plus milbemycin oxime chewable tablets was well accepted and safe.

Monthly administrations of milbemycin oxime plus afoxolaner chewable tablets to prevent Angiostrongylus vasorum infection in dogs

Background

Infection of dogs with the cardiopulmonary nematode Angiostrongylus vasorum may result in severe clinical disease therefore adequate prevention is necessary. A randomized, negative control, blinded study was conducted to evaluate the efficacy in the prevention of canine A. vasorum infection after monthly administrations of NexGard Spectra®, a novel chewable tablet formulation combining the insecticide and acaricide afoxolaner and the anthelmintic milbemycin oxime, in a multiple challenge (trickle infection) model.

Methods

Twenty beagle dogs were challenged orally with doses of approximately 32–43 third-stage larvae of A. vasorum once every other week on seven occasions (Study Days -7, 7, 21, 35, 49, 63 and 77). Ten dogs were administered NexGard Spectra® as close as possible to the minimum recommended dose of afoxolaner and milbemycin oxime, i.e. 2.5 mg/kg body weight and 0.5 mg/kg body weight, respectively, four times at monthly intervals (Study Days 0, 28, 56 and 84) while the remaining ten dogs served as untreated controls. For parasite recovery and count, dogs were euthanized humanely and necropsied six to eight days following the last treatment (Study Days 90–92). Beginning six weeks after first inoculation, faeces were collected on a bi-weekly basis and examined for first-stage larvae of A. vasorum.

Results

Untreated dogs harboured 39–95 adult A. vasorum (geometric mean, 66.4), while zero to 24 adult A. vasorum were recovered from the treated dogs (geometric mean, 3.4; P < 0.0001). Thus, efficacy of NexGard Spectra® administered at monthly intervals against incoming A. vasorum was 94.9 %. Compared to the untreated controls, larval excretion of the treated dogs was reduced by 99.9 % (P < 0.0001).

Conclusion

Results of this study demonstrate that NexGard Spectra®, when administered at monthly intervals, can effectively prevent canine A. vasorum infection.

Evaluation of a Barrier Dental Sealant in Dogs

A study was conducted in 40 healthy, randomly selected, client-owned, mixed and purebred dogs to assess the efficacy of a barrier dental sealant. All dogs showed evidence of dental plaque, calculus, or gingivitis. The dental sealant was applied to one side of the mouth following a professional teeth cleaning procedure and reapplied weekly for 8-weeks following the cleaning procedure. Dental parameters evaluated included plaque, calculus, gingivitis, and gingival bleeding indices. A statistically significant difference was detected between treated and untreated teeth compared with baseline values for plaque and calculus at weeks 4 and 8, gingivitis at week 4, and gingival bleeding time at week 8. A professional teeth cleaning procedure followed by a single application of the barrier dental sealant and weekly reapplication performed by a veterinarian or veterinary technician provided significant improvement in plaque and calculus indices during an 8-week period.

Efficacy of afoxolaner in a clinical field study in dogs naturally infested with Sarcoptes scabiei

The acaricidal efficacy of afoxolaner (NexGard(®), Merial) was evaluated against Sarcoptes scabiei var. canis in a field efficacy study, when administered orally at a minimum dose of 2.5 mg/kg to dogs naturally infested with the mites. Twenty mixed-breed dogs of either sex (6 males and 14 females), aged over 6 months and weighing 4-18 kg, were studied in this randomised controlled field efficacy trial. Dogs, naturally infested with Sarcoptes scabiei var. canis confirmed by skin scrapings collected prior to allocation, were randomly divided into two equal groups. Dogs in Group 1 were not treated. Dogs in Group 2 were treated on Days 0 and 28. On Days 0 (pre-treatment), 28 (pre-treatment) and 56, five skin scrapings of similar size were taken from different sites with lesions suggestive of sarcoptic mange. The extent of lesions was also recorded on Days 0, 28 and 56, and photographs were taken. Dogs treated orally with afoxolaner had significantly (p < 0.001) lower mite counts than untreated control animals at Days 28 and 56 with no mites recovered from treated dogs at these times (100% efficacy based on mite counts). In addition, dogs treated with NexGard had significantly (p < 0.05) better lesion resolution at Day 56 than Day 0; no treated dog showed pruritus compared to 7/10 dogs in the control group, 1/9 treated dogs had crusts compared to 5/10 controls and 8/9 dogs recovered 90% of hairs on lesions compared to 0/10 control dogs.

Efficacy of oral afoxolaner for the treatment of canine generalised demodicosis

The efficacy of oral treatment with a chewable tablet containing afoxolaner 2.27% w/w (NexGard^®, Merial) administered orally was assessed in eight dogs diagnosed with generalised demodicosis and compared with efficacy in eight dogs under treatment with a topical combination of imidacloprid/moxidectin (Advocate^®, Bayer). Afoxolaner was administered at the recommended dose (at least 2.5 mg/kg) on Days 0, 14, 28 and 56. The topical combination of imidacloprid/moxidectin was given at the same intervals at the recommended concentration. Clinical examinations and deep skin scrapings were performed every month in order to evaluate the effect on mite numbers and the resolution of clinical signs. The percentage reductions of mite counts were 99.2%, 99.9% and 100% on Days 28, 56 and 84, respectively, in the afoxolaner-treated group, compared to 89.8%, 85.2% and 86.6% on Days 28, 56 and 84 in the imidacloprid/moxidectin-treated group. Skin condition of the dogs also improved significantly from Day 28 to Day 84 in the afoxolaner-treated group. Mite reductions were significantly higher on Days 28, 56 and 84 in the afoxolaner-treated group compared to the imidacloprid/moxidectin-treated group. The results of this study demonstrated that afoxolaner, given orally, was effective in treating dogs with generalised demodicosis within a two-month period.

Immediate efficacy and persistent speed of kill of a novel oral formulation of afoxolaner (NexGardTM) against induced infestations with Ixodes ricinus ticks

Background

Ticks are hematophageous arthropods that transmit a wide spectrum of pathogens to human and animals. The ability of an acaricidal product to kill ticks quickly provides an important added benefit, especially as protecting dogs from tick bites remains the best preventive measure against tick-borne diseases. The speed of kill of afoxolaner in a novel soft chewable formulation (NexGard^TM) against induced infestations with Ixodes ricinus adult ticks was evaluated during a full-month negative controlled and blinded study following a single oral administration.

Methods

12 healthy beagle dogs were included and randomly allocated to 2 groups of six dogs each. One Group was a negative control while the other group was treated with an oral formulation of afoxolaner on Day 0. Tick infestations with 40 (±5) female and 10 male adult unfed I. ricinus were performed on Days -1, 7, 14, 21 and 28. To evaluate immediate efficacy, the number of live ticks were thumb counted at 12 and 24 hours post treatment. To evaluate the persistent speed of kill following further infestations, ticks were thumb counted 12 and 24 hours post infestations. Ticks were removed 24 hours post treatment or infestation.

Results

Afoxolaner starts to kill the pre-existing tick infestations rapidly with an immediate efficacy of 93.4% and 100% respectively at 12 h and 24 h post treatment. The persistent speed of kill of afoxolaner was significant (p < 0,05), as compared with untreated controls, at 12 hours after infestations at D7 and D21. Efficacy at 12 h was 76.6%, 41.9%, 36.9% and 38.5% at D7, D14, D21 and D28 respectively. Efficacy at 24 h ranged from 91% to 100% for the entire month.

Conclusions

This study demonstrated that besides the excellent acaricidal efficacy of afoxolaner after single oral administration, the product has a rapid speed of kill against one of the most important European tick species and controlled the weekly re-infestations for 28 days post treatment.

The ability of an oral formulation of afoxolaner to block the transmission of Babesia canis by Dermacentor reticulatus ticks to dogs

Background

Canine babesiosis due to Babesia canis is an endemic disease in many European countries. A vaccine is available in some countries, but it does not prevent the infection and just helps in reducing the gravity of clinical signs. Therefore, the major way to help preventing the disease is by controlling tick infestations on dogs.

To assess the preventive efficacy of afoxolaner (NexGard®), a new oral anti- flea and tick product, against Babesia canis infected adult Dermacentor reticulatus in an experimentally controlled study.

Methods

Sixteen healthy mixed breed adult dogs, negative for Babesia canis antibodies were included in a single centre, randomized, blinded and controlled study to evaluate the impact of treatment with afoxolaner on the transmission of Babesia canis to dogs exposed to Dermacentor reticulatus. The dogs were randomly allocated into two groups of 8 dogs each. One group remained untreated. In the other group, dogs were treated orally with a novel formulation of afoxolaner (NexGard®) on day 0. All dogs were infested each by 50 adult Dermacentor reticulatus ticks (equal sex ratio) at days 7, 14, 21 and 28. The Dermacentor reticulatus ticks were confirmed to harbour Babesia canis by Polymerase Chain Reaction (PCR).

Results

The treatment was well tolerated by all dogs without any adverse effects. Babesia canis was transmitted by D. reticulatus to all untreated control dogs, confirmed following demonstration of hyperthermia, detection of B. canis parasites in blood smears and PCR assay from blood and serology. These confirmed infected dogs were subsequently treated with imidocarb and diminazene. The treated dogs remained negative based on all criteria until the last study, Day 56, confirming that the oral treatment of dogs with NexGard® prevented transmission of Babesia canis and development of clinical babesiosis for up to 28 days.

Conclusion

This is the first demonstration that an oral acaricidal treatment may prevent the transmission of a pathogen despite the need for the tick to attach and start feeding before being killed by the acaricide.

Alzheimer's Prevention Education: If We Build It, Will They Come? www.AlzU.org

BACKGROUND

Internet-based educational interventions may be useful for impacting knowledge and behavioral change. However, in AD prevention, little data exists about which educational tools work best in terms of learning and interest in participating in clinical trials.

OBJECTIVES

Primary: Assess effectiveness of interactive webinars vs. written blog-posts on AD prevention learning. Secondary: Evaluate the effect of AD prevention education on interest in participating in clinical trials; Assess usability of, and user perceptions about, an online AD education research platform; Classify target populations (demographics, learning needs, interests).

DESIGN

Observational.

SETTING

Online.

PARTICIPANTS

Men/Women, aged 25+, recruited via facebook.com.

INTERVENTION

Alzheimer's Universe (www.AlzU.org) education research platform.

MEASUREMENTS

Pre/post-test performance, self-reported Likert-scale ratings, completion rates.

RESULTS

Over two-weeks, 4268 visits were generated. 503 signed-up for a user account (11.8% join rate), 196 participated in the lessons (39.0%) and 100 completed all beta-testing steps (19.9%). Users randomized to webinar instruction about AD prevention and the stages of AD demonstrated significant increases (p=0.01) in pre vs. post-testing scores compared to blog-post intervention. Upon joining, 42% were interested in participating in a clinical trial in AD prevention. After completing all beta-test activities, interest increased to 86%. Users were primarily women and the largest category was children of AD patients. 66.3% joined to learn more about AD prevention, 65.3% to learn more about AD treatment.

CONCLUSIONS

Webinar-based education led to significant improvements in learning about AD prevention and the stages of AD. AlzU.org participation more than doubled interest in AD prevention clinical trial participation. Subjects were quickly and cost-effectively recruited, and highly satisfied with the AD education research platform. Based on these data, we will further refine AlzU.org prior to public launch and aim to study the effectiveness of 25 interactive webinar-based vs. blog-post style lessons on learning and patient outcomes, in a randomized, within-subjects design trial.

Implementing a systematic response to medication errors

Healthcare delivery is associated with various risks and it is unlikely that these can ever be completely eliminated. Medicine management is an area known to involve errors. This article describes how implementing a systematic response to medication errors enables health professionals to identify individual and organisational failures and reduce adverse patient outcomes.

Oral transmucosal fentanyl citrate versus placebo for painful dressing changes: a crossover trial

OBJECTIVE

Fentanyl is a potent opioid that is well absorbed via the oral mucosa. It can be given as an oral lozenge. The onset of analgesia is rapid and matches the pain profile observed at dressing changes.

METHOD

Patients experiencing pain during daily dressing changes were given entonox plus either placebo or oral transmucosal fentanyl citrate (OTFC) for two consecutive dressing changes in a randomised double-blind placebo-controlled crossover trial.

RESULTS

Nine patients were recruited. The mean worst pain score during dressing changes was 7/10 with placebo and 4/10 with OTFC; the reduction in pain achieved with OTFC was significant. The mean number of breaths of entonox taken during the dressing change was 27.67 with placebo and 4.67 with OTFC; the reduction in the number of entonox breaths with OTFC was significant. One patient in the OTFC group suffered nausea.

CONCLUSION

Compared with placebo, OTFC improved analgesia during painful dressing changes without an increase in side-effects.

Astrovirus-induced synthesis of nitric oxide contributes to virus control during infection

Astrovirus is one of the major causes of infant and childhood diarrhea worldwide. Our understanding of astrovirus pathogenesis trails behind our knowledge of its molecular and epidemiologic properties. Using a recently developed small-animal model, we investigated the mechanisms by which astrovirus induces diarrhea and the role of both the adaptive and innate immune responses to turkey astrovirus type-2 (TAstV-2) infection. Astrovirus-infected animals were analyzed for changes in total lymphocyte populations, alterations in CD4(+)/CD8(+) ratios, production of virus-specific antibodies (Abs), and macrophage activation. There were no changes in the numbers of circulating or splenic lymphocytes or in CD4(+)/CD8(+) ratios compared to controls. Additionally, there was only a modest production of virus-specific Abs. However, adherent spleen cells from infected animals produced more nitric oxide (NO) in response to ex vivo stimulation with lipopolysaccharide. In vitro analysis demonstrated that TAstV-2 induced macrophage production of inducible nitric oxide synthase. Studies using NO donors and inhibitors in vivo demonstrated, for the first time, that NO inhibited astrovirus replication. These studies suggest that NO is important in limiting astrovirus replication and are the first, to our knowledge, to describe the potential role of innate immunity in astrovirus infection.

Astrovirus induces diarrhea in the absence of inflammation and cell death

Astroviruses are a leading cause of infantile viral gastroenteritis worldwide. Very little is known about the mechanisms of astrovirus-induced diarrhea. One reason for this is the lack of a small-animal model. Recently, we isolated a novel strain of astrovirus (TAstV-2) from turkeys with the emerging infectious disease poult enteritis mortality syndrome. In the present studies, we demonstrate that TAstV-2 causes growth depression, decreased thymus size, and enteric infection in infected turkeys. Infectious TAstV-2 can be recovered from multiple tissues, including the blood, suggesting that there is a viremic stage during infection. In spite of the severe diarrhea, histopathologic changes in the intestine were mild and there was a surprising lack of inflammation. This may be due to the increased activation of the potent immunosuppressive cytokine transforming growth factor beta during astrovirus infection. These studies suggest that the turkey will be a useful small-animal model with which to study astrovirus pathogenesis and immunity.

Estimates of conserved microsynteny among the genomes of Glycine max, Medicago truncatula and Arabidopsis thaliana

A growing body of research indicates that microsynteny is common among dicot genomes. However, most studies focus on just one or a few genomic regions, so the extent of microsynteny across entire genomes remains poorly characterized. To estimate the level of microsynteny between Medicago truncatula (Mt) and Glycine max (soybean), and also among homoeologous segments of soybean, we used a hybridization strategy involving bacterial artificial chromosome (BAC) contigs. A Mt BAC library consisting of 30,720 clones was screened with a total of 187 soybean BAC subclones and restriction fragment length polymorphism (RFLP) probes. These probes came from 50 soybean contig groups, defined as one or more related BAC contigs anchored by the same low-copy probe. In addition, 92 whole soybean BAC clones were hybridized to filters of HindIII-digested Mt BAC DNA to identify additional cases of cross-hybridization after removal of those soybean BACs found to be repetitive in Mt. Microsynteny was inferred when at least two low-copy probes from a single soybean contig hybridized to the same Mt BAC or when a soybean BAC clone hybridized to three or more low-copy fragments from a single Mt BAC. Of the 50 soybean contig groups examined, 54% showed microsynteny to Mt. The degree of conservation among 37 groups of soybean contigs was also investigated. The results indicated substantial conservation among soybean contigs in the same group, with 86.5% of the groups showing at least some level of microsynteny. One contig group was examined in detail by a combination of physical mapping and comparative sequencing of homoeologous segments. A TBLASTX similarity search was performed between 1,085 soybean sequences on the 50 BAC contig groups and the entire Arabidopsis genome. Based on a criterion of sequence homologues <100 kb apart, each with an expected value of < or =1e-07, seven of the 50 soybean contig groups (14%) exhibited microsynteny with Arabidopsis.

Localization of astrovirus in experimentally infected turkeys as determined by in situ hybridization

Twenty-one 3-day-old turkey poults from British United Turkeys of America were orally inoculated with a recently characterized astrovirus, TAstV-2, isolated from turkeys with poult enteritis and mortality syndrome. At 1, 2, 3, 4, 5, 7, and 9 days postinfection (dpi), three inoculated birds were euthanatized, and tissues (intestines, spleen, bursa, and thymus) were collected immediately into 10% neutral buffered formalin. Inoculated birds were diarrheic by 3 dpi, and frothy feces persisted throughout the experimental period. Histologically, there was only slight evidence of enteric damage, which was characterized by mild epithelial necrosis, lamina propria infiltrates, minimal villus atrophy, and mild crypt hyperplasia. In situ hybridization, using a negative sense digoxigenin-labeled riboprobe to the capsid gene of TAstV-2, revealed viral RNA in intestinal epithelial cells at the basal margins of the villi, in distal small intestine, and in cecum at 2 dpi, with subsequent extension to epithelium of the large intestine and proximal small intestine (3-5 dpi). Minimal virus remained by 9 dpi.

Soybean genomic survey: BAC-end sequences near RFLP and SSR markers

We are building a framework physical infrastructure across the soybean genome by using SSR (simple sequence repeat) and RFLP (restriction fragment length polymorphism) markers to identify BACs (bacterial artificial chromosomes) from two soybean BAC libraries. The libraries were prepared from two genotypes, each digested with a different restriction enzyme. The BACs identified by each marker were grouped into contigs. We have obtained BAC- end sequence from BACs within each contig. The sequences were analyzed by the University of Minnesota Center for Computational Genomics and Bioinformatics using BLAST algorithms to search nucleotide and protein databases. The SSR-identified BACs had a higher percentage of significant BLAST hits than did the RFLP-identified BACs. This difference was due to a higher percentage of hits to repetitive-type sequences for the SSR-identified BACs that was offset in part, however, by a somewhat larger proportion of RFLP-identified significant hits with similarity to experimentally defined genes and soybean ESTs (expressed sequence tags). These genes represented a wide range of metabolic functions. In these analyses, only repetitive sequences from SSR-identified contigs appeared to be clustered. The BAC-end sequences also allowed us to identify microsynteny between soybean and the model plants Arabidopsis thaliana and Medicago truncatula. This map-based approach to genome sampling provides a means of assaying soybean genome structure and organization.

Soybean genomic survey: BAC-end sequences near RFLP and SSR markers

We are building a framework physical infrastructure across the soybean genome by using SSR (simple sequence repeat) and RFLP (restriction fragment length polymorphism) markers to identify BACs (bacterial artificial chromosomes) from two soybean BAC libraries. The libraries were prepared from two genotypes, each digested with a different restriction enzyme. The BACs identified by each marker were grouped into contigs. We have obtained BAC- end sequence from BACs within each contig. The sequences were analyzed by the University of Minnesota Center for Computational Genomics and Bioinformatics using BLAST algorithms to search nucleotide and protein databases. The SSR-identified BACs had a higher percentage of significant BLAST hits than did the RFLP-identified BACs. This difference was due to a higher percentage of hits to repetitive-type sequences for the SSR-identified BACs that was offset in part, however, by a somewhat larger proportion of RFLP-identified significant hits with similarity to experimentally defined genes and soybean ESTs (expressed sequence tags). These genes represented a wide range of metabolic functions. In these analyses, only repetitive sequences from SSR-identified contigs appeared to be clustered. The BAC-end sequences also allowed us to identify microsynteny between soybean and the model plants Arabidopsis thaliana and Medicago truncatula. This map-based approach to genome sampling provides a means of assaying soybean genome structure and organization.

Echocardiographic predictors of survival in low gradient aortic stenosis

Echocardiographic predictors of long-term survival for patients with low gradient aortic stenosis who undergo aortic valve replacement have not been previously reported. This study shows that patients with larger pre- and postoperative left ventricular volumes, a lower mean preoperative aortic pressure gradient, and failure of volumes to decrease and ejection fraction to increase postoperatively may have a poor prognosis.

MR artifacts, heat production, and ferromagnetism of Guglielmi detachable coils

The Guglielmi detachable coil, a platinum microcoil used in the endovascular treatment of intracranial aneurysms, was studied in vitro for its MR imaging artifacts, heat production, and ferromagnetism. In addition, imaging artifacts were studied in vivo in eight patients who had undergone therapeutic placement of these coils. These devices displayed a very low level of MR artifact and no ferromagnetism or heat production. We conclude that the Guglielmi detachable coil is compatible with MR imaging in terms of both safety and image quality.

Provision of clean injecting equipment

Providing clean needles and syringes to injecting drug users is one established strategy to prevent the spread of HIV and other blood borne infections ( 1 ). Our A&E department had been faced with problems from intravenous (IV) drug users requesting clean injecting equipment, and we wanted to know how other A&Es dealt with such requests, and whether they experienced similar problems.

Distinguishing detection from identification in subliminal auditory perception: a review and critique of Merikle's study

Assertions made by Merikle (1988) regarding audio subliminal messages were tested. Seventeen participants were presented subliminal messages embedded in a white-noise cover, and three signal-to-noise (S/N) detection ratios were examined. Participants were asked to guess message presence and message content, to determine subjective/objective thresholds. Results showed that participants were unable to identify target words presented in this audio subliminal stimulus format beyond chance levels.

Microcatheter embolization of non-neurologic traumatic vascular lesions

PURPOSE

The authors report their experience over a 28-month period with embolization of 23 non-neurologic traumatic vascular lesions in 21 patients with use of a coaxial microcatheter coil delivery system.

PATIENTS AND METHODS

The injuries included pseudoaneurysms (n = 17), arteriovenous fistulas (n = 3), and sites of extravasation (n = 3) and were caused by gunshot, shotgun, and stab wounds, as well as motor vehicle accidents and iatrogenic trauma. All microcatheter embolizations except one were performed with 2.2-F Tracker-18 catheters inserted coaxially through 5.0-5.5-F guiding catheters. In one case, a coaxial 3-F Teflon catheter was used. In all cases platinum microcoils (almost all non-fibril) and/or straight platinum embolization wires (with fibrils) were used.

RESULTS

Twenty-one (91%) of 23 vascular lesions were successfully occluded with use of the microcatheter system. The two cases in which microcatheter embolization failed were successfully managed by using larger catheters and steel coils. Two patients with hepatic vascular lesions (one site of extravasation and a pseudoaneurysm) and one patient with a lower extremity arteriovenous fistula required two procedures each for successful treatment. Procedures were life-saving in at least two patients. Two lesions recurred during follow-up ranging from 3 days to 17 months. Both of these recurrences were successfully treated with transcatheter embolization, in one case with use of microcatheters.

CONCLUSION

Microcatheter embolization with platinum coils and wires is an effective means for treating traumatic vascular lesions. A coaxial microcatheter system allows for easier, more rapid coil/wire delivery to smaller, spasm-prone arteries in such cases.

Implementation of practice guidelines in a clinical setting using a computerized knowledge base (Iliad)

We present the implementation of the indications for surgery for three surgical operations--cholecystectomy, cataract extraction, and knee arthroscopy--in a medical expert system, called Iliad. This implementation operates in the preauthorization service of IHC Health Plans (an insurance company in Salt Lake City) as a basis for reimbursement of services. Patient data collection forms, derived from Iliad knowledge base, were used by 13 participating surgeons to document the objective patient observations that justify the surgery and, then were faxed to IHC where a trained nurse input the data in Iliad. Iliad's decisions and reports on any deviations from guidelines are communicated back to the care provider. The study evaluates the impact of the computerized implementation on process, as measured by a questionnaire, and on outcome as measured by rate of approvals, documentation level, rate of requests, and average cost. The prospective implementation of the computerized guidelines has performed reliably, has been perceived as a preferred alternative to the old preauthorization system, and, most importantly, has enhanced significantly the level of documentation permitting evaluation and determination of appropriateness before surgery.

Generation and characterization of antipeptide antibodies to rat cytochrome P-450 side-chain cleavage enzyme

In this report, we describe the generation of immunologic probes to rat P-450scc. Two regions of the P-450scc amino acid sequence were identified (internal domain: amino acids 421-441; carboxy terminal domain: amino acids 509-526), chemically synthesized and used as immunogens in rabbits. Antibody production was monitored by enzyme-linked immunoassay (EIA) and Western blot analyses. Antisera were successfully generated to each of the P-450scc regions that recognized the entire 49 kDa rat P-450scc protein. Antiserum directed to the internal domain of P-450scc showed broad species crossreactivity, whereas antiserum directed to the carboxy terminal domain of P-450scc crossreacted with only rat and mouse. Both antisera were useful for Western blot and immunocytochemical analyses of rat P-450scc expression. In addition to recognizing the major 49 kDa P-450scc protein, each antiserum also recognized lower molecular weight species. Antiserum directed to the internal domain of P-450scc specifically recognized a 42 kDa species, whereas antiserum directed to the carboxy terminal domain specifically recognized an 8 kDa species. We hypothesize that the two lower molecular weight immunoreactive species are generated by proteolytic cleavage of rat P-450scc between the internal and carboxy terminal epitopes.

Identification and immunochemical characterization of a major placental secretory protein related to the prolactin-growth hormone family, prolactin-like protein-C

Trophoblast cells of the rat chorioallantoic placenta synthesize and secrete a number of proteins structurally related to pituitary PRL. During the purification of one member of the placental PRL family, PRL-like protein-A (PLP-A), we identified a major contaminating protein with a similar mol wt but possessing a more acidic pI (5.9-6.1) and different immunoreactivities. After isolation by two-dimensional gel electrophoresis, the more acidic contaminating protein was electroeluted, and its N-terminal amino acid sequence was determined by gas phase sequencing. The N-terminal sequence showed considerable homology with members of the PRL family, including characteristic positioning of cysteine residues at amino acids 4 and 11. The newly identified protein species have been termed PLP-C based on their structural similarity with pituitary PRL. The protein was further characterized by the generation of specific immunological probes. Antibodies were generated to electrophoretically purified protein and to a chemically synthesized peptide representing amino acids 11-32 of its N-terminal sequence. Each antiserum specifically recognized two major species migrating at approximately 25 and 29 kDa, respectively. The 29-kDa species specifically bound to Concanavalin-A, while the 25-kDa species failed to bind to the lectin. Furthermore, the 29-kDa species could be converted to the 25-kDa species by enzymatic deglycosylation. The antisera have also been used to examine the cell- and temporal-specific patterns of expression. The immunoreactive protein species (25 and 29 kDa) were localized primarily to spongiotrophoblast cells present in the junctional zone of the chorioallantoic placenta. Expression was initiated after midgestation and increased during the remaining part of gestation. In summary, PLP-C is a major secretory protein produced by spongiotrophoblast cells during the second half of gestation.

Expression of alkaline phosphatase in differentiated rat labyrinthine trophoblast tissue

In this report, we describe the generation of specific antibodies to rat alkaline phosphatase and the temporal and regional characteristics of alkaline phosphatase expression during maturation of the rat chorioallantoic placenta. An antipeptide antiserum was generated to the amino terminal 15 amino acids of rat alkaline phosphatase. The antiserum specifically recognized alkaline phosphatase. Alkaline phosphatase expression was monitored in the junctional and labyrinth zones of the chorioallantoic placenta by Western and Northern blot analyses. Alkaline phosphatase protein and mRNA were present in both the junctional and labyrinth zones on day 13 of gestation. As gestation advanced, alkaline phosphatase mRNA and protein expression decreased below the limits of detection in the junctional zone, while alkaline phosphatase expression increased in the labyrinth zone. Labyrinthine alkaline phosphatase migrated predominantly as a 95-kDa species, whereas rat kidney expressed exclusively the 75-kDa species. Enzymatic deglycosylation of the 75- and 95-kDa alkaline phosphatase species resulted in the generation of a 55-kDa species. In summary, alkaline phosphatase expression is a useful indicator of trophoblast differentiation.

Color Doppler sonography of the scrotum

Color Doppler sonography is a noninvasive, rapidly performed, and relatively inexpensive imaging technique for use in the diagnosis of scrotal pathology. Its major and proven role is in the evaluation of patients with acute scrotal pain, for which it is likely to become the primary imaging modality. Further work is needed to determine whether color Doppler is a useful diagnostic adjunct in evaluating patients with varicoceles and scrotal masses.

Identification and characterization of a new member of the prolactin family, placental lactogen-I variant

This report describes the identification and characterization of a new member of the placental prolactin (PRL) family, termed placental lactogen-I variant (PL-Iv). PL-Iv was isolated from medium conditioned by late gestation placental explants. Rat PL-Iv was found to be closely related to rat PL-I. Amino-terminal sequence analysis indicated that PL-Iv shared approximately 88% sequence identity with the amino terminus of PL-I. PL-Iv proteins cross-reacted with antiserum to recombinant mouse PL-I and PL-Iv mRNA hybridized with a PL-I cDNA. Multiple PL-I and PL-Iv species were present in placental cytosol. Despite the structural similarities between PL-I and PL-Iv, distinct differences were also evident. Antibodies generated to the amino-terminal 19 amino acids of PL-Iv specifically recognized PL-Iv, while failing to recognize PL-I. Secreted PL-Iv had an affinity for concanavalin A, whereas secreted PL-I lacked affinity for the lectin. PL-I was predominantly secreted as a 36-40-kDa species and PL-Iv was predominantly secreted as a 33-kDa species. Furthermore, PL-I and PL-Iv were synthesized at different times during gestation and by different cell types. PL-I was synthesized by trophoblast giant cells during the first half of gestation, while PL-Iv was predominantly synthesized by spongiotrophoblast cells during the later stages of gestation. PL-Iv was shown to stimulate the proliferation of rat Nb2 lymphoma cells, an in vitro measure of lactogenic activity. In summary, PL-Iv shares structural similarities with PL-I; however, it shows other structural differences in addition to unique cell- and temporal-specific patterns of expression in the rat chorioallantoic placenta.

Potential Ambergris Odorants From Abietic Acid

In contrast to literature reports the rearrangement of abietic acid (1) catalysed by 96% sulfuric acid gives a mixture (3 : 1) of two dienoic acids (19) and (27) whose structures have been established by spectral means. Compounds containing the diene system are unstable, severely limiting their use in synthesis. However, removal of the diene functionality affords stable compounds which, despite difficulties in stereochemical control, are suitable for further modification. The synthesis of compounds containing a five- membered C-ring common to a class of potential amber odorants is reported.