Retrospective Evaluation of Horses Diagnosed with Neuroborreliosis on Postmortem Examination: 16 Cases (2004-2015)

BACKGROUND

Equine neuroborreliosis (NB), Lyme disease, is difficult to diagnose and has limited description in the literature.

OBJECTIVE

Provide a detailed description of clinical signs, diagnostic, and pathologic findings of horses with NB.

ANIMALS

Sixteen horses with histologically confirmed NB.

METHODS

Retrospective review of medical records at the University of Pennsylvania and via an ACVIM listserv query with inclusion criteria requiring possible exposure to Borrelia burgdorferi and histologic findings consistent with previous reports of NB without evidence of other disease.

RESULTS

Sixteen horses were identified, 12 of which had additional evidence of NB. Clinical signs were variable including muscle atrophy or weight loss (12), cranial nerve deficits (11), ataxia (10), changes in behavior (9), dysphagia (7), fasciculations (6), neck stiffness (6), episodic respiratory distress (5), uveitis (5), fever (2), joint effusion (2), and cardiac arrhythmias (1). Serologic analysis was positive for B. burgdorferi infection in 6/13 cases tested. CSF abnormalities were present in 8/13 cases tested, including xanthochromia (4/13), increased total protein (5/13; median: 91 mg/dL, range: 25-219 mg/dL), and a neutrophilic (6/13) or lymphocytic (2/13) pleocytosis (median: 25 nucleated cells/μL, range: 0-922 nucleated cells/μL). PCR on CSF for B. burgdorferi was negative in the 7 cases that were tested.

CONCLUSION AND CLINICAL IMPORTANCE

Diagnosis of equine NB is challenging due to variable clinical presentation and lack of sensitive and specific diagnostic tests. Negative serology and normal CSF analysis do not exclude the diagnosis of NB.

Acquired factor V inhibitor after exposure to topical human thrombin related to an otorhinolaryngological procedure

Acquired factor V (FV) inhibitors occur rarely and classically develop after exposure to bovine thrombin. The clinical presentation is variable, ranging from asymptomatic with incidental laboratory abnormalities to significant bleeding. With the development of human-derived thrombin agents, bovine thrombin is less frequently used. We report a case of an acquired FV inhibitor that developed in a patient after exposure to human thrombin used as a hemostatic agent during an otorhinolaryngology surgical procedure. Our review of the literature revealed only one prior reported case of FV inhibitor after exposure to human thrombin. Hematologists and surgeons should be aware of this rare, but potentially life-threatening, complication in the postprocedural setting.

Florida Initiative for Quality Cancer Care: Changes in Psychosocial Quality of Care Indicators Over a 3-Year Interval

PURPOSE

Identifying and addressing psychosocial concerns is increasingly recognized as an important aspect of cancer care that needs to be improved. As part of the Florida Initiative for Quality Cancer Care, medical record reviews were conducted to evaluate cancer care, including psychosocial care, at oncology practices in Florida in 2006. Results were subsequently disseminated to the practices, and performance was reassessed at the same practices in 2009.

METHODS

Data were available for patients with colorectal, breast, and non-small-cell lung cancer first seen by a medical oncologist in 2006 (n = 1,609) and 2009 (n = 1,720) at the same 10 practice sites. Performance on each psychosocial indicator was evaluated for overall change over time and for variability in change based on practice site and cancer type.

RESULTS

The percentage of patients identified as having a problem in emotional well-being increased significantly over time, from 24% to 31% among those assessed (P = .002) and from 13% to 16% overall (P = .026). In contrast, there no significant changes over time in assessment of emotional well-being (53% to 51%, P = .661) or in action taken to address problems (57% to 45%, P = .098).

CONCLUSION

Findings suggest more intensive efforts than audit and feedback will be required to improve the quality of psychosocial care and that greater recognition of problems with emotional well-being may tax the ability of practices to link patients with appropriate services. Systematic research is needed to identify and disseminate effective strategies for implementing routine assessment of well-being and addressing the increased demands for care this will generate.

Florida Initiative for Quality Cancer Care: improvements in breast cancer quality indicators during a 3-year interval

BACKGROUND

The Florida Initiative for Quality Cancer Care (FIQCC), composed of 11 practice sites across Florida, conducted its initial evaluation of adherence to breast cancer quality of care indicators (QCI) in 2006, with feedback provided to encourage quality improvement efforts at participating sites. In this study, our objective was to reassess changes over time resulting from these efforts.

STUDY DESIGN

Quality care indicators were derived from the Quality Oncology Practice Initiative, the National Comprehensive Cancer Network, the American College of Surgeons, and expert panel consensus. Medical records were reviewed for breast cancer patients first seen by medical oncologists in 2009 at the FIQCC sites, using the same performance indicators as in 2006. Statistical comparisons of 2006 vs 2009 data across sites were made by Pearson chi-square exact test using Monte Carlo estimation.

RESULTS

Charts of 602 patients in 2006 and 636 patients in 2009 were compared. Performance on medical oncology QCI improved over time for documentation of clinical trial participation discussion (p = 0.001), documentation of consent for chemotherapy (p = 0.047), definitive surgery done after neoadjuvant chemotherapy (p = 0.017), and planned dose of chemotherapy consistent with published regimens (p = 0.02). Improvements in surgical QCI were seen for documentation of specimen orientation (p < 0.001), inking of margins (p < 0.0001), and performance of sentinel lymph node biopsy (p = 0.035).

CONCLUSIONS

The 2006 FIQCC study identified several medical and surgical oncology QCI improvement needs. Quality improvement efforts resulted in better performance for numerous metrics, therefore speaking to the benefits of reassessment of adherence to performance indicators to guide QCI efforts.

Florida Initiative for Quality Cancer Care: improvements on colorectal cancer quality of care indicators during a 3-year interval

BACKGROUND

The quality of cancer care has become a national priority; however, there are few ongoing efforts to assist medical oncology practices in identifying areas for improvement. The Florida Initiative for Quality Cancer Care is a consortium of 11 medical oncology practices that evaluates the quality of cancer care across Florida. Within this practice-based system of self-assessment, we determined adherence to colorectal cancer quality of care indicators (QCIs) in 2006, disseminated results to each practice and reassessed adherence in 2009. The current report focuses on evaluating the direction and magnitude of change in adherence to QCIs for colorectal cancer patients between the 2 assessments.

STUDY DESIGN

Medical records were reviewed for all colorectal cancer patients seen by a medical oncologist in 2006 (n = 489) and 2009 (n = 511) at 10 participating practices. Thirty-five indicators were evaluated individually and changes in QCI adherence over time and by site were examined.

RESULTS

Significant improvements were noted from 2006 to 2009, with large gains in surgical/pathological QCIs (eg, documenting rectal radial margin status, lymphovascular invasion, and the review of ≥ 12 lymph nodes) and medical oncology QCIs (documenting planned treatment regimen and providing recommended neoadjuvant regimens). Documentation of perineural invasion and radial margins significantly improved; however, adherence remained low (47% and 71%, respectively). There was significant variability in adherence for some QCIs across institutions at follow-up.

CONCLUSIONS

The Florida Initiative for Quality Cancer Care practices conducted self-directed quality-improvement efforts during a 3-year interval and overall adherence to QCIs improved. However, adherence remained low for several indicators, suggesting that organized improvement efforts might be needed for QCIs that remained consistently low over time. Findings demonstrate how efforts such as the Florida Initiative for Quality Cancer Care are useful for evaluating and improving the quality of cancer care at a regional level.

Obesity and oral disease - a challenge for dentistry

The prevalence of overweight and obesity is rising in many developed and developing countries and, most worryingly, among children. Within the EU, Scotland has the highest prevalence, more than twice that of the Netherlands, and in England almost a quarter of children now enter primary school either overweight or obese, rising to one in three on leaving at age 11 years. Whilst most epidemiological data is based on body mass index, this is not a reliable indicator of individual adiposity and morbidity risk. The association between excess adiposity and type 2 diabetes is well recognised and the latter carries implications for oral disease and dental treatment. Current research has not established a clear association between excess adiposity and caries prevalence, however, there is evidence for a higher prevalence of chronic periodontal disease in obese populations. There is some evidence that this is not mediated solely by diabetes, but by secretion by adipose tissue of chemical mediators of inflammation, including cytokines and hormones, which could modify the response of the periodontal tissues to the oral environment. Dental professionals must become aware of this growing problem, of the demands that the rising obesity prevalence will place on dental care services and the need for bariatric dental facilities. Together, with service providers, dental professionals must prepare for the challenge ahead.

Measuring quality of care in the treatment of colorectal cancer: the moffitt quality practice initiative

PURPOSE

The Moffitt Quality Practice Initiative (MQPI) is a practice-based system of quality self-assessment, the ultimate goal of which is to improve the quality of cancer care at a statewide level. The initial phase of this project focused on developing procedures, determining feasibility, and evaluating utility for assessing quality of care for colorectal cancer within an existing affiliate network.

PATIENTS AND METHODS

Representatives from four oncology groups selected quality measures consistent with evidence-, consensus-, and safety-based guidelines that could be abstracted from medical records. Trained abstractors then reviewed records of all eligible colorectal patients seen by each practice in 2004. Frequencies of responses for each indicator were tabulated for overall and practice-specific level of adherence and were compared among practices.

RESULTS

Adherence was uniformly high for several indicators, including confirmatory pathology report, staging information, and chemotherapy discussion or recommendation. Lower adherence was evident across practices for performance of carcinoembryonic tests and complete colonoscopic evaluations. Significant variation among practices was evident only for consent for chemotherapy.

CONCLUSION

The initial phase of MQPI demonstrated the feasibility and utility of assessing quality indicators for colorectal cancer among members of an existing affiliate network. Findings identified areas where adherence to care was uniformly high, but also identified areas where both overall and practice-specific adherence were less than optimal. These efforts lay the groundwork for expanding MQPI in several directions that have in common the potential to improve the quality of cancer care on a statewide basis.

Toll-like receptor alterations in myelodysplastic syndrome

Recent studies have implicated the innate immunity system in the pathogenesis of myelodysplastic syndromes (MDS). Toll-like receptor (TLR) genes encode key innate immunity signal initiators. We recently identified multiple genes, known to be regulated by TLRs, to be overexpressed in MDS bone marrow (BM) CD34+ cells, and hypothesized that TLR signaling is abnormally activated in MDS. We analyzed a large cohort of MDS cases and identified TLR1, TLR2 and TLR6 to be significantly overexpressed in MDS BM CD34+ cells. Deep sequencing followed by Sanger resequencing of TLR1, TLR2, TLR4 and TLR6 genes uncovered a recurrent genetic variant, TLR2-F217S, in 11% of 149 patients. Functionally, TLR2-F217S results in enhanced activation of downstream signaling including NF-κB activity after TLR2 agonist treatment. In cultured primary BM CD34+ cells of normal donors, TLR2 agonists induced histone demethylase JMJD3 and interleukin-8 gene expression. Inhibition of TLR2 in BM CD34+ cells from patients with lower-risk MDS using short hairpin RNA resulted in increased erythroid colony formation. Finally, RNA expression levels of TLR2 and TLR6, as well as presence of TLR2-F217S, are associated with distinct prognosis and clinical characteristics. These findings indicate that TLR2-centered signaling is deregulated in MDS, and that its targeting may have potential therapeutic benefit in MDS.

Evaluating the quality of colorectal cancer care in the state of Florida: results from the Florida Initiative for Quality Cancer Care

PURPOSE

The Florida Initiative for Quality Cancer Care (FIQCC) was established to evaluate the quality of cancer care at the regional level across the state of Florida. This study assessed adherence to validated quality indicators in colorectal cancer (CRC) and the variability in adherence by practice site, volume, and patient age.

METHODS

The FIQCC is a consortium of 11 medical oncology practices in Florida. Medical record reviews were conducted for 507 patients diagnosed with CRC and seen as new medical oncology patients in 2006. Thirty-five indicators were evaluated individually and categorized across clinical domains and components of care.

RESULTS

The mean adherence for 19 of 35 individual indicators was > 85%. Pathology reports were compliant on reporting depth of tumor invasion (96%; range, 86% to 100%), grade (93%; range, 72% to 100%), and status of proximal and distal surgical resection margins (97%; range. 86% to 100%); however, documentation of lymphovascular and perineural invasion did not meet adherence standards (76%; range, 53% to 100% and 39%; range, 5% to 83%, respectively). Among patients with nonmetastatic rectal cancer, documentation of the status of surgical radial margins was consistently low across sites (42%; range, 0% to 100%; P = .19). Documentation of planned treatment regimens for adjuvant chemotherapy was noted in only 58% of eligible patients.

CONCLUSION

In this large regional initiative, we found high levels of adherence to more than half of the established quality indicators. Although the quality of care delivered within FIQCC practices seems to be high, several components of care were identified that warrant further scrutiny on both a systemic level and at individual centers.