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Papadimitriou-Olivgeris M, Monney P, Frank M, Tzimas G, Tozzi P, Kirsch M, Van Hemelrijck M, Bauernschmitt R, Epprecht J, Guery B, Hasse B. Evaluation of the 2023 Duke-International Society of Cardiovascular Infectious Diseases Criteria in a Multicenter Cohort of Patients With Suspected Infective Endocarditis. Clin Infect Dis 2024; 78:949-955. [PMID: 38330243 PMCID: PMC11006096 DOI: 10.1093/cid/ciae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/28/2023] [Accepted: 01/26/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Since publication of Duke criteria for infective endocarditis (IE) diagnosis, several modifications have been proposed. We aimed to evaluate the diagnostic performance of the Duke-ISCVID (International Society of Cardiovascular Infectious Diseases) 2023 criteria compared to prior versions from 2000 (Duke-Li 2000) and 2015 (Duke-ESC [European Society for Cardiology] 2015). METHODS This study was conducted at 2 university hospitals between 2014 and 2022 among patients with suspected IE. A case was classified as IE (final IE diagnosis) by the Endocarditis Team. Sensitivity for each version of the Duke criteria was calculated among patients with confirmed IE based on pathological, surgical, and microbiological data. Specificity for each version of the Duke criteria was calculated among patients with suspected IE for whom IE diagnosis was ruled out. RESULTS In total, 2132 episodes with suspected IE were included, of which 1101 (52%) had final IE diagnosis. Definite IE by pathologic criteria was found in 285 (13%), 285 (13%), and 345 (16%) patients using the Duke-Li 2000, Duke-ESC 2015, or the Duke-ISCVID 2023 criteria, respectively. IE was excluded by histopathology in 25 (1%) patients. The Duke-ISCVID 2023 clinical criteria showed a higher sensitivity (84%) compared to previous versions (70%). However, specificity of the new clinical criteria was lower (60%) compared to previous versions (74%). CONCLUSIONS The Duke-ISCVID 2023 criteria led to an increase in sensitivity compared to previous versions. Further studies are needed to evaluate items that could increase sensitivity by reducing the number of IE patients misclassified as possible, but without having detrimental effect on specificity of Duke criteria.
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Affiliation(s)
| | - Pierre Monney
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michelle Frank
- Department of Cardiology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Georgios Tzimas
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Piergiorgio Tozzi
- Department of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Matthias Kirsch
- Department of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mathias Van Hemelrijck
- Department of Cardiac Surgery, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Robert Bauernschmitt
- Department of Cardiac Surgery, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Jana Epprecht
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Benoit Guery
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Barbara Hasse
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Sarsiat L, Garrigos T, Houhamdi L, Dauwalder O, Kuli B, Braunberger E, Belmonte O, Fournier PE, Miltgen G. Case series of 12 Bartonella quintana endocarditis from the Southwest Indian Ocean. PLoS Negl Trop Dis 2023; 17:e0011606. [PMID: 37676863 PMCID: PMC10508605 DOI: 10.1371/journal.pntd.0011606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/19/2023] [Accepted: 08/20/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Bartonella spp. are fastidious bacteria frequently identified as the cause of blood culture-negative (BCN) endocarditis. However, Bartonella infections are difficult to diagnose in routine laboratory testing and their incidence is probably underestimated. We investigated the epidemiological and clinical features of Bartonella endocarditis cases diagnosed between 2009 and 2021 on Reunion Island (Southwest Indian Ocean). METHOD We retrospectively included all patients diagnosed with Bartonella endocarditis at Reunion Island University Hospital during this period. Endocarditis was diagnosed on the basis of microbiological findings, including serological tests (IFA) and PCR on cardiac valves, and the modified Duke criteria. We used then the multispacer typing (MST) method to genotype the available Bartonella strains. FINDINGS We report 12 cases of B. quintana endocarditis on Reunion Island (83.3% in men, median patient age: 32 years). All the patients originated from the Comoros archipelago. The traditional risk factors for B. quintana infection (homelessness, alcoholism, exposure to body lice) were absent in all but two of the patients, who reported head louse infestations in childhood. Previous heart disease leading to valve dysfunction was recorded in 50% of patients. All patients underwent cardiac valve surgery and antimicrobial therapy with a regimen including doxycycline. All patients presented high C-reactive protein concentrations, anemia and negative blood cultures. The titer of IgG antibodies against Bartonella sp. exceeded 1:800 in 42% of patients. Specific PCR on cardiac valves confirmed the diagnosis of B. quintana endocarditis in all patients. Genotyping by the MST method was performed on four strains detected in preserved excised valves and was contributive for three, which displayed the MST6 genotype. CONCLUSIONS Bartonella quintana is an important cause of infective endocarditis in the Comoros archipelago and should be suspected in patients with mitral valve dysfunction and BCN from this area.
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Affiliation(s)
- Ludivine Sarsiat
- Laboratoire de Bactériologie, CHU Félix Guyon, Saint-Denis, La Réunion, France
| | - Thomas Garrigos
- Laboratoire de Bactériologie, CHU Félix Guyon, Saint-Denis, La Réunion, France
- UMR Processus Infectieux en Milieu Insulaire Tropical (PIMIT), CNRS 9192, INSERM U1187, IRD 249, Université de La Réunion, Saint-Denis, La Réunion, France
| | - Linda Houhamdi
- CNR des Rickettsies, Coxiella et Bartonella, IHU-Méditerranée Infection, Marseille, France
| | - Olivier Dauwalder
- Plateau de Microbiologie Moléculaire Spécialisé et de Séquençage, Institut des Agents Infectieux, Centre de Biologie et Pathologie Nord, Hospices Civils de Lyon, Lyon, France
| | - Barbara Kuli
- Service de Maladies Infectieuses, CHU Félix Guyon, Saint-Denis, La Réunion, France
| | - Eric Braunberger
- Service de Chirurgie Cardio-thoracique, CHU Félix Guyon, Saint-Denis, La Réunion, France
| | - Olivier Belmonte
- Laboratoire de Bactériologie, CHU Félix Guyon, Saint-Denis, La Réunion, France
| | - Pierre-Edouard Fournier
- CNR des Rickettsies, Coxiella et Bartonella, IHU-Méditerranée Infection, Marseille, France
- UMR Vecteurs—Infections Tropicales et Méditerranéennes (VITROME), Université d’Aix-Marseille, IRD, AP-HM, SSA, IHU-Méditerranée Infection, Marseille, France
| | - Guillaume Miltgen
- Laboratoire de Bactériologie, CHU Félix Guyon, Saint-Denis, La Réunion, France
- UMR Processus Infectieux en Milieu Insulaire Tropical (PIMIT), CNRS 9192, INSERM U1187, IRD 249, Université de La Réunion, Saint-Denis, La Réunion, France
- Centre Régional en Antibiothérapie (CRAtb) de La Réunion, France
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Liu L, Du L, He S, Sun T, Kong F, Liu Y, Xu Y. Subculturing and Gram staining of blood cultures flagged negative by the BACTEC™ FX system: Optimizing the workflow for detection of Cryptococcus neoformans in clinical specimens. Front Microbiol 2023; 14:1113817. [PMID: 37007533 PMCID: PMC10050354 DOI: 10.3389/fmicb.2023.1113817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/28/2023] [Indexed: 03/17/2023] Open
Abstract
ObjectiveTo investigate whether an incubation time of 5 days (Aerobic/F, Anaerobic/F) and 14 days (Myco/F) blood culture bottles is sufficient to prevent false-negative results.MethodsWe evaluated 1,244 blood bottles (344 patients) defined as negative by the BACTEC™ FX system. We also reviewed published cases and our own cases of bloodstream infection caused by Cryptococcus neoformans and simulated different scenarios, including different inoculation concentrations, bottle types, and clinical isolates.ResultsTwo bottles (0.16%) were found to contain C. neoformans when subcultured and Gram stained. A 5-day protocol with Aerobic/F bottles was insufficient for the growth of C. neoformans in some cases, and C. neoformans grew better in Myco/F bottles than in Aerobic/F bottles.ConclusionSubculturing and Gram staining after a 5-day protocol were important for the detection of C. neoformans, and Myco/F bottles should be collected for the blood culture of C. neoformans.
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Affiliation(s)
- Lingli Liu
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Lijun Du
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Department of Clinical Laboratory, Nanchong Central Hospital, the Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
- Jinan University, Guangzhou, Guangdong, China
| | - Shuquan He
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Department of Clinical Laboratory, Longhua District Central Hospital, Shenzhen, China
- Teaching Hospital of Guangdong Medical University, Guangdong, China
| | - Tianshu Sun
- Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Fanrong Kong
- Center for Infectious Diseases and Microbiology Laboratory Services, ICPMR—Pathology West, Westmead Hospital, University of Sydney, Westmead, NSW, Australia
| | - Yali Liu
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
- Graduate School, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Yali Liu,
| | - Yingchun Xu
- Department of Laboratory Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
- Yingchun Xu,
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Bartonella Endocarditis in Spain: Case Reports of 21 Cases. Pathogens 2022; 11:pathogens11050561. [PMID: 35631082 PMCID: PMC9143151 DOI: 10.3390/pathogens11050561] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 12/04/2022] Open
Abstract
Blood culture negative endocarditis (BCNE) is frequent in infective endocarditis (IE). One of the causes of BCNE is fastidious microorganisms, such as Bartonella spp. The aim of this study was to describe the epidemiologic, clinical characteristics, management and outcomes of patients with Bartonella IE from the “Spanish Collaboration on Endocarditis-Grupo de Apoyo al Manejo de la Endocarditis infecciosa en España (GAMES)”cohort. Here we presented 21 cases of Bartonella IE. This represents 0.3% of a total of 5590 cases and 2% of the BCNE from the GAMES cohort. 62% were due to Bartonella henselae and 38% to Bartonella quintana. Cardiac failure was the main presenting form (61.5% in B. hensalae, 87.5% in B. quintana IE) and the aortic valve was affected in 85% of the cases (76% in B. henselae, 100% in B. quintana IE). Typical signs such as fever were recorded in less than 40% of patients. Echocardiography showed vegetations in 92% and 100% of the patients with B. henselae and B. quintana, respectively. Culture was positive only in one patient and the remaining were diagnosed by serology and PCR. PCR was the most useful tool allowing for diagnosis in 16 patients (100% of the studied valves). Serology, at titers recommended by guidelines, only coincided with PCR in 52.4%. Antimicrobial therapy, in different combinations, was used in all cases. Surgery was performed in 76% of the patients. No in-hospital mortality was observed. One-year mortality was 9.4%. This article remarks the importance for investigating the presence of Bartonella infection as causative agent in all BCNE since the diagnosis needs specific microbiological tools and patients could benefit of a specific treatment.
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Pecoraro AJK, Herbst PG, Pienaar C, Taljaard J, Prozesky H, Janson J, Doubell AF. Modified Duke/European Society of Cardiology 2015 clinical criteria for infective endocarditis: time for an update? Open Heart 2022; 9:openhrt-2021-001856. [PMID: 35534094 PMCID: PMC9086646 DOI: 10.1136/openhrt-2021-001856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 04/21/2022] [Indexed: 11/21/2022] Open
Abstract
Background The diagnosis of infective endocarditis (IE) is based on the modified Duke/European Society of Cardiology (ESC) 2015 clinical criteria. The sensitivity of the criteria is unknown in South Africa, but high rates of blood culture negative endocarditis (BCNIE), coupled with a change in the clinical features of IE, may limit the sensitivity. Methods The Tygerberg Endocarditis Cohort study prospectively enrolled patients with IE between November 2019 and June 2021. A standardised protocol for organism detection, with management of patients by an Endocarditis Team, was employed. Patients with definite IE by pathological criteria were analysed to determine the sensitivity of the current clinical criteria. Results Eighty consecutive patients with IE were included of which 45 (56.3%) had definite IE by pathological criteria. In patients with definite IE by pathological criteria, 26/45 (57.8%) of patients were classified as definite IE by clinical criteria. BCNIE was present in 25/45 (55.6%) of patients and less than three minor clinical criteria were present in 32/45 (75.6%) of patients. The elevation of Bartonella serology to a major microbiological criterion of the modified Duke/ESC 2015 clinical criteria would increase the sensitivity (57.8% vs 77.8%; p=0.07). Conclusion The sensitivity of the modified Duke/ESC 2015 clinical criteria is lower than expected in patients with IE in South Africa, primarily due to the high rates of Bartonella-associated BCNIE. The elevation of Bartonella serology to a major microbiological criterion, similar to the status of Coxiella burnetii in the current criteria, would increase the sensitivity. The majority of patients with definite IE by pathological criteria had less than three minor criteria present.
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Affiliation(s)
- Alfonso Jan Kemp Pecoraro
- Division of Cardiology, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Philipus George Herbst
- Division of Cardiology, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Colette Pienaar
- Division of Medical Microbiology, Department of Pathology, Stellenbusch University Faculty of Medicine and Health Sceinces, Cape Town, Western Cape, South Africa.,National Health Laboratory Service, Johannesburg, Gauteng, South Africa
| | - Jantjie Taljaard
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Hans Prozesky
- Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Jacques Janson
- Division of Cardiothoracic Surgery, Department of Surgery, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Anton Frans Doubell
- Division of Cardiology, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
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Infective endocarditis in Africa: an urgent call for more data. THE LANCET GLOBAL HEALTH 2022; 10:e8-e9. [DOI: 10.1016/s2214-109x(21)00489-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 10/12/2021] [Indexed: 12/27/2022] Open
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Pecoraro AJK, Pienaar C, Herbst PG, Poerstamper S, Joubert L, Taljaard J, Prozesky H, Janson J, Newton-Foot M, Doubell AF. Causes of infective endocarditis in the Western Cape, South Africa: a prospective cohort study using a set protocol for organism detection and central decision making by an endocarditis team. BMJ Open 2021; 11:e053169. [PMID: 34873007 PMCID: PMC8650472 DOI: 10.1136/bmjopen-2021-053169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Blood culture negative infective endocarditis (BCNIE) poses both a diagnostic and therapeutic challenge. High rates of BCNIE reported in South Africa have been attributed to antibiotic use prior to blood culture sampling. OBJECTIVES To assess the impact of a systematic approach to organism detection and identify the causes of infective endocarditis (IE), in particular causes of BCNIE. DESIGN Prospective cohort study. METHODS The Tygerberg Endocarditis Cohort study prospectively enrolled patients with IE between November 2019 and February 2021. A set protocol for organism detection with management of patients by an endocarditis team was employed. This prospective cohort was compared with a retrospective cohort of patients with IE admitted between January 2017 and December 2018. RESULTS One hundred and forty patients with IE were included, with 75 and 65 patients in the retrospective and prospective cohorts, respectively. Baseline demographic characteristics were similar with a mean age of 39.6 years and male predominance (male sex=67.1%). The rate of BCNIE was lower in the prospective group (28/65 or 43.1%) compared with the retrospective group (47/75 or 62.7%; p=0.039). The BCNIE in-hospital mortality rate in the retrospective cohort was 23.4% compared with 14.2% in the prospective cohort (p=0.35). A cause was identified (including non-culture techniques) in 86.2% of patients in the prospective cohort, with Staphylococcus aureus (26.2%), Bartonella species (20%) and the viridans streptococci (15.3%) being most common. CONCLUSION The introduction of a set protocol for organism detection, managed by an endocarditis team, has identified Staphylococcusaureus as the most common cause of IE and identified non-culturable organisms, in particular Bartonella quintana, as an important cause of BCNIE. A reduction in in-hospital mortality in patients with BCNIE was observed, but did not reach statistical significance.
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Affiliation(s)
- Alfonso Jan Kemp Pecoraro
- Medicine, Division of Cardiology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Colette Pienaar
- Microbiology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Philippus George Herbst
- Medicine, Division of Cardiology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Simon Poerstamper
- Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Lloyd Joubert
- Medicine, Division of Cardiology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Jantjie Taljaard
- Medicine, Division of Cardiology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Hans Prozesky
- Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Jacques Janson
- Surgery, Division of Cardiothoracic Surgery, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Mae Newton-Foot
- Microbiology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Anton Frans Doubell
- Medicine, Division of Cardiology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
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Maggi R, Breitschwerdt EB, Qurollo B, Miller JC. Development of a Multiplex Droplet Digital PCR Assay for the Detection of Babesia, Bartonella, and Borrelia Species. Pathogens 2021; 10:pathogens10111462. [PMID: 34832618 PMCID: PMC8620149 DOI: 10.3390/pathogens10111462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
We describe the development, optimization, and validation of a multiplex droplet digital PCR (ddPCR) assay for the simultaneous detection of Babesia, Bartonella, and Borrelia spp. DNA from several sample matrices, including clinical blood samples from animals and humans, vectors, in-vitro infected human and animal cell lines, and tissues obtained from animal models (infected with Bartonella and/or B. burgdorferi). The multiplex ddPCR assay was able to detect 31 Bartonella, 13 Borrelia, and 24 Babesia species, including Theileria equi, T. cervi, and Cytauxzoon felis. No amplification of Treponema or Leptospira spp. was observed. Sensitivity of 0.2-5 genome equivalent DNA copies per microliter was achieved for different members of the Bartonella and Borrelia genus, depending on the species or matrix type (water or spiked blood DNA) tested. The ddPCR assay facilitated the simultaneous detection of co-infections with two and three vector-borne pathogens comprising four different genera (Babesia, Bartonella, Borrelia, and Theileria) from clinical and other sample sources.
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Affiliation(s)
- Ricardo Maggi
- Department of Clinical Sciences, The Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27607, USA; (E.B.B.); (B.Q.)
- Galaxy Diagnostics, Inc., 6 Davis Drive, Suite 201, Research Triangle Park, NC 27709, USA;
- Correspondence:
| | - Edward B. Breitschwerdt
- Department of Clinical Sciences, The Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27607, USA; (E.B.B.); (B.Q.)
- Galaxy Diagnostics, Inc., 6 Davis Drive, Suite 201, Research Triangle Park, NC 27709, USA;
| | - Barbara Qurollo
- Department of Clinical Sciences, The Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27607, USA; (E.B.B.); (B.Q.)
| | - Jennifer C. Miller
- Galaxy Diagnostics, Inc., 6 Davis Drive, Suite 201, Research Triangle Park, NC 27709, USA;
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