Measuring return on investment of outreach by community health workers

Community health workers (CHWs) are effective in improving access to health care, promoting client knowledge and behavior change, and contributing to improved health status of individuals. However, few outreach programs have evaluated the financial impact of CHWs on health care systems and policies. A longitudinal repeated measures design was used to assess the return on investment (ROI) of outreach by CHWs employed by Denver Health Community Voices. Service utilization, charges and reimbursements for 590 underserved men were analyzed 9 months before and after interaction with a CHW. Primary and specialty care visits increased and urgent care, inpatient, and outpatient behavioral health care utilization decreased, resulting in a reduction of monthly uncompensated costs by $14,244. Program costs were $6,229 per month and the ROI was 2.28:1.00, a savings of $95,941 annually. These data provide evidence of economic contributions that CHWs make to a public safety net system and inform policy making regarding program sustainability.

Serum 17-alpha-hydroxyprogesterone and corticosterone concentrations in dogs with nonadrenal neoplasia and dogs with suspected hyperadrenocorticism

OBJECTIVE

To assess serum 17-alpha-hydroxyprogesterone (17OHP) and corticosterone concentrations in dogs with nonadrenal neoplasia and dogs being screened for hyperadrenocorticism.

DESIGN

Prospective study.

ANIMALS

16 clinically normal dogs, 35 dogs with nonadrenal neoplasia, and 127 dogs with suspected hyperadrenocorticism.

PROCEDURE

ACTH stimulation tests were performed in all dogs. Baseline serum cortisol and corticosterone concentrations were measured in the healthy dogs; baseline serum cortisol concentration and ACTH-stimulated cortisol, corticosterone, and 17OHP concentrations were measured in all dogs. Endogenous plasma ACTH concentration was also measured before administration of ACTH in dogs with neoplasia.

RESULTS

In 35 dogs with neoplasia, 31.4% had high serum 17OHP concentration and 22.9% had high serum corticosterone concentration. Of the 127 dogs with suspected hyperadrenocorticism, 59 (46.5%) had high ACTH-stimulated cortisol concentrations; of those, 42 of 59 (71.2%) and 32 of 53 (60.4%) had high serum 17OHP and corticosterone concentrations, respectively. Of dogs with serum cortisol concentration within reference range after ACTH administration, 9 of 68 (13.2%) and 7 of 67 (10.4%) had high serum 17OHP and corticosterone concentrations, respectively. In the dogs with neoplasia and dogs suspected of having hyperadrenocorticism, post-ACTH serum hormone concentrations were significantly correlated.

CONCLUSIONS AND CLINICAL RELEVANCE

Serum concentrations of 17OHP or corticosterone after administration of ACTH may be high in dogs with nonadrenal neoplasia and no evidence of hyperadrenocorticism. Changes in serum 17OHP or corticosterone concentrations after administration of ACTH are proportionate with changes in cortisol concentration.

Canine digital tumors: a veterinary cooperative oncology group retrospective study of 64 dogs

We compared clinical characteristics and outcomes for dogs with various digital tumors. Medical records and histology specimens of affected dogs from 9 veterinary institutions were reviewed. Risk factors examined included age, weight, sex, tumor site (hindlimb or forelimb), local tumor (T) stage, metastases, tumor type, and treatment modality. The Kaplan-Meier product limit method was used to determine the effect of postulated risk factors on local disease-free interval (LDFI), metastasis-free interval (MFI), and survival time (ST). Outcomes were thought to differ significantly between groups when P < or = .003. Sixty-four dogs were included. Squamous cell carcinoma (SCC) accounted for 33 (51.6%) of the tumors. Three dogs presented with or developed multiple digital SCC. Other diagnoses included malignant melanoma (MM) (n = 10; 15.6%), osteosarcoma (OSA) (n = 4; 6.3%), hemangiopericytoma (n = 3; 4.7%), benign soft tissue tumors (n = 5; 7.8%), and malignant soft tissue tumors (n = 9; 14%). Fourteen dogs with malignancies had black hair coats, including 5 of the 10 dogs with MM. Surgery was the most common treatment and, regardless of the procedure, had a positive impact on survival. None of the patient variables assessed, including age, sex, tumor type, site, and stage, had a significant impact on ST. Both LDFI and MFI were negatively affected by higher T stage, but not by type of malignancy. Although metastasis at diagnosis correlated with a shorter LDFI, it did not have a significant impact on ST. On the basis of these findings, early surgical intervention is advised for the treatment of dogs with digital tumors, regardless of tumor type or the presence of metastatic disease.

Corticosterone- and aldosterone-secreting adrenocortical tumor in a dog

A dog was evaluated for clinical signs suggestive of hypercortisolemia. Serum biochemical testing revealed hypernatremia and hypokalemia. Serum cortisol concentration after injection of ACTH was less than the lower reference limit. An adrenal gland tumor was visualized via ultrasonography and computed tomography. Histologic examination confirmed that the mass was an adrenocortical carcinoma. Excess adrenal secretion of corticosterone was hypothesized to be the cause of the signs of glucocorticoid excess. Serum corticosterone secretion was high before and after ACTH injection, compared with clinically normal dogs and dogs with hypercortisolemia and classic hyperadrenocorticism. Hyperaldosteronemia was detected as well. Treatment with mitotane was instituted and successful for a period of 4-months until the dog was euthanatized for neurologic problems that were most likely unrelated to endocrine disease.

Hepatozoon spp.: pathological and partial 18S rRNA sequence analysis from three Brazilian dogs

Molecular and histopathological studies were carried out on samples from three Brazilian dogs with persistent hepatozoonosis parasitemia. Canine hepatozoonosis was confirmed by finding gametocytes in blood smears. Histopathological examination of skeletal muscle biopsy revealed muscle degeneration and atrophy, and degenerating/regenerating myofibers, similar to the muscle degeneration caused by Hepatozoon americanum . However, the large cystic structures typical of H. americanum were not observed in muscle biopsies from these dogs. Partial 18S rRNA sequences amplified by PCR from the three Brazilian samples demonstrated closest similarity to the Hepatozoon sp. Fukuoka described in Japan (>99% identity). These results indicate that both additional clinical cases and genes need examination in order to determine the phylogenetic relatedness among canid Hepatozoon species.

Malignant neoplasia in four alpacas

Malignant neoplasia in 4 alpacas was characterized by acute onset of clinical signs and rapidly deteriorating condition. Postmortem examination revealed metastatic or multicentric neoplasia in the abdominal organs of alpacas 1, 3, and 4 and an extensive thoracic mass in alpaca 2. Immunohistochemical stains supported a diagnosis of B-cell lymphosarcoma in alpacas 1-3 and a neuroendocrine neoplasm in alpaca 4.

Ocular metastasis of a vaccine-associated fibrosarcoma in a cat

A 6-year-old, neutered male domestic shorthair cat was evaluated for a recurrent vaccine-associated fibrosarcoma. The cat had three excisions of the tumour prior to presentation and was referred for radiation therapy. Ten months following treatment with radiation therapy, the cat was presented again for a cloudy appearance to the eye. An exenteration was performed, and biopsy revealed fibrosarcoma. At the same time, two discrete pulmonary nodules were identified on thoracic radiographs. Two doses of doxorubicin (20 mg/m(2)) and cyclophosphamide (100 mg/m(2)) were administered intravenously 3 weeks apart. Despite treatment, the pulmonary nodule doubled in size. This case represents the first antemortem report of ocular metastasis of a vaccine-associated sarcoma and supports the highly aggressive nature of these tumours.

Canine mammary tumor cells transfected with B7-1 or B7-2 stimulate proliferation of peripheral blood mononuclear cells

Neoplastic cells are believed to evade the immune system due, in part, to their inability to successfully provide a secondary, costimulatory signal for a T lymphocyte proliferative response. This report describes the generation and investigation of genetically engineered canine mammary tumor (CMT) cells that express canine B7-1, canine B7-2, or human B7-2. These transfected cells were used as stimulators in an allogeneic, costimulation assay. CMT cells transfected with canine B7-1 induced the greatest proliferation (7-fold increase), followed by CMT cells transfected with canine B7-2 (5-fold increase). The specificity of the canine B7-2 stimulatory response was demonstrated by a 38% reduction in proliferation caused by an anti-canine B7-2 blocking antibody. These results suggest that canine mammary tumor cells transfected with canine B7-1 or canine B7-2 may be useful for immunotherapeutic purposes.

Hepatozoonosis in dogs: 22 cases (1989-1994)

OBJECTIVE

To document hepatozoonosis in dogs from Alabama and Georgia and to report associated clinical signs, method of diagnosis, response to treatment, and course of disease.

DESIGN

Retrospective case series.

ANIMALS

22 dogs in which Hepatozoon canis was identified by microscopic examination of skeletal muscle.

PROCEDURE

We reviewed medical records of all dogs with a definitive diagnosis of hepatozoonosis that were referred to the Auburn University Small Animal Clinic between 1989 and 1994.

RESULTS

Diagnoses were confirmed by microscopic identification of H canis schizont or merozoite stages in skeletal muscle. The gametocyte stage was not detected in smears of blood obtained from a peripheral vein, buffy-coat smears, or bone marrow evaluation. Common clinical signs included fever, cachexia, ocular discharge, pain, stiffness, and paresis. Laboratory abnormalities included marked leukocytosis, hypoglycemia, hypoalbuminemia, mild anemia, hyperphosphatemia, and high alkaline phosphatase activity. Periosteal bone proliferation was evident radiographically in 18 of 22 dogs. Renal lesions included amyloidosis (1 dog), interstitial nephritis (3), and mesangioproliferative glomerulonephritis (4). Treatment with the anticoccidial drug toltrazuril, despite an initial favorable response, failed to prevent relapse in all but 3 of 21 treated dogs. Mean survival time was 12.6 +/- 2.2 months, with a mean time of remission before recurrence of clinical signs of 6 months.

CLINICAL IMPLICATIONS

H canis infection in dogs can be associated with a distinct clinical syndrome that involves chronic myositis, debilitation, and death. The dogs of this report represent the first substantial number of domestic dogs naturally infected with H canis in the United States outside of the Texas Gulf Coast. Hepatozoon canis appears to be a serious pathogen in the United States that is becoming more widespread geographically.

Modulation by canine interferon-gamma of major histocompatibility complex and tumor-associated antigen expression in canine mammary tumor and melanoma cell lines

In an effort to enhance the antigenicity of canine tumor cells, canine interferon-gamma (CnIFN-gamma) was applied in vitro to seven canine mammary tumor (CMT) and two canine melanoma (CML) cell lines. Surface expression of major histocompatibility complex (MHC) antigens and tumor-associated antigens (TAA) was measured by a flow cytometric fluorescence assay using commercially available anti-MHC antibodies, and anti-canine TAA monoclonal antibodies generated against CMT and CML cell lines. Compared to constitutive antigen levels in untreated cells, treatment with CnIFN-gamma resulted in increased expression of MHC class I and II antigens (up to 19- and 167-fold, respectively) and a TAA (up to 5-fold) by CMT cell lines, and increased expression of class I antigen (131-fold) by one CML and of class II antigen (18-fold) by the other CML cell line. Expression of MHC antigens and a TAA by tumor cells was increased by Cn-IFN-gamma treatment, and such an increase may be of potential benefit in tumor cell recognition and rejection by the immune system.

Histological findings in corneal stromal abscesses of 11 horses: correlation with cultures and cytology

Histopathology was compared to culture results and cytology from horses with corneal stromal abscess at the Auburn University and the Ohio State University Veterinary Teaching Hospitals. Significant bacteria were not isolated in culture or seen on histopathology in any of the horses. Although most bacteria infecting equine corneas can be isolated with blood and MacConkey's agars, failure to detect bacterial growth may not rule out infection because anaerobic or intracellular bacteria would not be isolated. The inability to visualise bacterial organisms on histological sections did not rule out their presence in the tissue, because there is often destruction of bacteria by neutrophils, macrophages and antibiotic therapy greatly reducing their numbers. Fungal keratitis was diagnosed by histopathology in 4 of 11 eyes (36%) and keratitis with no aetiological agent in 7 of 11 eyes (64%). Nine of 11 horses (82%) had a prominent neutrophilic stromal infiltrate and 2 (18%) had a predominantly pyogranulomatous reaction. Two of the 4 lesions that showed histological evidence of fungal infection were positive for identifiable fungi on culture and cytology. Fungal cultures of the other 2 cases with histological evidence of mycotic keratitis were negative or grew unidentifiable fungi which were considered pathogenic because, on histopathological sections, fungal hyphae were found deep in the corneal stroma surrounded by an inflammatory reaction. In 3 of 6 cases where fungi were recovered on culture, they were considered contaminants based on lack of evidence of organisms in histopathological sections. Histopathology and the use of special stains were important in the interpretation of culture and cytology results.