Ventral dermatitis in rowi (Apteryx rowi) due to cutaneous larval migrans

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Rowi on a crèche island showed loss of feathers and dermatitis.

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We identified cutaneous larval migrans, possibly due to Trichostrongylus.

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This is the first instance of cutaneous larval migrans to be recorded in birds.

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Fatal complications resulted in the death of eight birds from aspergillosis.

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Intensive conservation management can result in pathways for novel infections.

The rowi is a critically endangered species of kiwi. Young birds on a crèche island showed loss of feathers from the ventral abdomen and a scurfy dermatitis of the abdominal skin and vent margin. Histology of skin biopsies identified cutaneous larval migrans, which was shown by molecular sequencing to be possibly from a species of Trichostrongylus as a cause of ventral dermatitis and occasional ulcerative vent dermatitis. The predisposing factors that led to this disease are suspected to be the novel exposure of the rowi to parasites from seabirds or marine mammals due to the island crèche and the limited management of roost boxes. This is the first instance of cutaneous larval migrans to be recorded in birds. Severe and fatal complications of the investigation resulted in the death of eight birds of aspergillosis and pulmonary complications associated with the use of bark as a substrate in hospital. Another bird died of renal failure during the period of hospitalisation despite oral and intravenous fluid therapy. The initiating cause of the renal failure was not determined. These complications have the potential to undermine the working relationship between wildlife veterinarians and conservation managers. This case highlights that intensive conservation management can result in increased opportunities for novel routes of cross-species pathogen transmission.

Lack of efficacy of monepantel against Teladorsagia circumcincta and Trichostrongylus colubriformis

After reports of the apparent failure of monepantel to reduce the egg counts of goats on a farm in the lower North Island of New Zealand, faecal egg count reduction tests were conducted in goats and lambs resident on the property, and a confirmatory, slaughter study was conducted using 12 sheep, sourced elsewhere, that were grazed on the farm for approximately 5 weeks. In the egg count reduction test in goats, 8 animals were given monepantel at 3.9 mg/kg (just over 1.5× the sheep dose rate of 2.5mg/kg), whilst four received 7.7 mg/kg (just over 3× the sheep dose). In the egg count reduction test in sheep, 15 lambs were treated with 3.0mg/kg of monepantel. For the confirmatory study, the sheep were housed indoors for 2 weeks before half were treated with 2.9 mg/kg monepantel and the animals were killed for worm counts 9 days later. There was no evidence of efficacy in either egg count reduction test, or in the goats, the two dose rates used appeared equally ineffective. Likewise, there were no significant reductions in egg counts or worm burdens in the slaughter study. Monepantel was ineffective against at least two gastrointestinal nematode species, Teladorsagia circumcincta and Trichostrongylus colubriformis. These findings represent the first report from the field of resistance having developed to the anthelmintic monepantel with severe resistance developing in more than one species after being administered on 17 separate occasions to different stock classes and in less than 2 years of the product first being used on the farm in question.

Informing future research priorities into the psychological and social problems faced by cancer survivors: a rapid review and synthesis of the literature

PURPOSE

To establish what is known regarding the psychological and social problems faced by adult cancer survivors (people who are living with and beyond a diagnosis of cancer) and identify areas future research should address.

METHOD

A rapid search of published literature reviews held in electronic data bases was under taken. Inclusion and exclusion criteria, and removal of duplicated papers, reduced the initial number of papers from 4051 to 38. Twenty-two review papers were excluded on grounds of quality and 16 review papers were selected for appraisal.

RESULTS

The psychological and social problems for cancer survivors are identified as depression, anxiety, distress, fear of recurrence, social support/function, relationships and impact on family, and quality of life. A substantial minority of people surviving cancer experience depression, anxiety, and distress or fear associated with recurrence or follow up. There is some indication that social support is positively associated with better outcomes. Quality of life for survivors of cancer appears generally good for most people, but an important minority experience a reduction in quality of life, especially those with more advanced disease and reduced social and economic resources. The majority of research knowledge is based on women with breast cancer. The longer term implications of cancer survival have not been adequately explored.

CONCLUSIONS

Focussing well designed research in the identified areas where less is already known about the psychological and social impact of cancer survival is likely to have the greatest impact on the wellbeing of people surviving cancer.

Characterization of three novel HLA alleles with silent nucleotide substitutions

Characterization of the novel HLA alleles B*35:11:03, B*42:01:03, and B*51:01:35 is described.

Characterization of a novel allele, HLA-B*15:228

B*15:228 differs from B*15:01:01:01 at three nucleotides in exon 4.

Quality of drug prescribing in older patients: is there a problem and can we improve it?

Older patients are at high risk of suboptimal prescribing (overuse, underuse and misuse of drugs), which can lead to serious adverse drug reactions (ADR). About one in four patients admitted to hospital are prescribed at least one inappropriate medication and up to 20% of all inpatient deaths are attributed to potentially preventable ADR. Lists of drugs to avoid (unnecessary or where risks outweigh benefits) and drugs not to be omitted (strong indications if there are no contraindications) can assist in identifying suboptimal prescribing although, to date, no trials have established the ability of such screening, by itself, to improve prescribing quality. Remedial strategies proven to be effective in randomized trials include detailed appraisal of medication lists by multidisciplinary teams, which involve geriatricians and close liaison with specialist clinical pharmacists. A multifaceted quality improvement strategy is proposed that includes an aspirational target of no more than five different drugs be regularly prescribed to vulnerable older patients. Achieving this target involves prioritizing drug selection on the basis of strength of indication which may run counter to current disease-specific clinical guideline recommendations based on trials that have excluded most older patients. Such a strategy is worthy of further evaluation in a multicentre randomized trial.

Objective assessment of the alterations in wrist mobility with the fastrak(®) system following dorsal capsulodesis

The treatment for scapholunate dissociation is challenging and its management is varied depending on type, severity and duration of injury, and surgeon's preferred technique. This study aimed to objectively assess the variations in the range and patterns of wrist movements using the Fastrak(®) system in patients having undergone Blatt's dorsal capsulodesis (BDC). The wrist movements were successively measured between the operated and unoperated wrists, while the patients performed set tasks. Seventeen patients agreed to participate in the study. Following BDC the mean flexion loss was 23° (range 10°-38°). However, functional tasks revealed that the BDC did not adversely affect the function of the operated wrist. This novel study demonstrates objectively the functional restrictions that patients are likely to experience postoperatively following BDC. It would be interesting to note the pattern of wrist motion using the Fastrak(®) system in various other clinical settings.

What are the most effective strategies for improving quality and safety of health care?

There is now a plethora of different quality improvement strategies (QIS) for optimizing health care, some clinician/patient driven, others manager/policy-maker driven. Which of these are most effective remains unclear despite expressed concerns about potential for QIS-related patient harm and wasting of resources. The objective of this study was to review published literature assessing the relative effectiveness of different QIS. Data sources comprising PubMed Clinical Queries, Cochrane Library and its Effective Practice and Organization of Care database, and HealthStar were searched for studies of QIS between January 1985 and February 2008 using search terms based on an a priori QIS classification suggested by experts. Systematic reviews of controlled trials were selected in determining effect sizes for specific QIS, which were compared as a narrative meta-review. Clinician/patient driven QIS were associated with stronger evidence of efficacy and larger effect sizes than manager/policy-maker driven QIS. The most effective strategies (>10% absolute increase in appropriate care or equivalent measure) included clinician-directed audit and feedback cycles, clinical decision support systems, specialty outreach programmes, chronic disease management programmes, continuing professional education based on interactive small-group case discussions, and patient-mediated clinician reminders. Pay-for-performance schemes directed to clinician groups and organizational process redesign were modestly effective. Other manager/policy-maker driven QIS including continuous quality improvement programmes, risk and safety management systems, public scorecards and performance reports, external accreditation, and clinical governance arrangements have not been adequately evaluated with regard to effectiveness. QIS are heterogeneous and methodological flaws in much of the evaluative literature limit validity and generalizability of results. Based on current best available evidence, clinician/patient driven QIS appear to be more effective than manager/policy-maker driven QIS although the latter have, in many instances, attracted insufficient robust evaluations to accurately determine their comparative effectiveness.