Diabetes and Covid-19: Clinical implications and novel management strategies

From the outset of the Covid-19 pandemic, diabetes has been identified as attracting higher rates of severe infection and associated mortality. Our understanding of the mechanisms behind these observations continue to develop but it is clear that the comorbidities associated with diabetes play a key role. Here we provide a brief overview of the clinical implications relevant to Covid-19 infection in diabetes and outline the changes we have instituted to adapt the management of both acute hyperglycaemic emergencies and routine diabetes care during the current pandemic.

Exogenous T3 toxicosis following consumption of a contaminated weight loss supplement

A 42-year-old male presented with a one-week history of palpitations and sweating episodes. The only significant history was of longstanding idiopathic dilated cardiomyopathy. Initial ECG demonstrated a sinus tachycardia. Thyroid function testing, undertaken as part of the diagnostic workup, revealed an un-measureable thyroid-stimulating hormone (TSH) and free thyroxine (T₄). Upon questioning the patient reported classical thyrotoxic symptoms over the preceding weeks. Given the persistence of symptoms free tri-iodothyronine (T₃) was measured and found to be markedly elevated at 48.9 pmol/L (normal range: 3.1-6.8 pmol/L). No goitre or nodular disease was palpable in the neck. Historically there had never been any amiodarone usage. Radionucleotide thyroid uptake imaging (¹²³I) demonstrated significantly reduced tracer uptake in the thyroid. Upon further questioning the patient reported purchasing a weight loss product online from India which supposedly contained sibutramine. He provided one of the tablets and laboratory analysis confirmed the presence of T₃ in the tablet. Full symptomatic resolution and normalised thyroid function ensued upon discontinuation of the supplement.

LEARNING POINTS

Free tri-iodothyronine (T₃) measurement may be useful in the presence of symptoms suggestive of thyrotoxicosis with discordant thyroid function tests.Thyroid uptake scanning can be a useful aid to differentiating exogenous hormone exposure from endogenous hyperthyroidism.Ingestion of thyroid hormone may be inadvertent in cases of exogenous thyrotoxicosis.Medicines and supplements sourced online for weight loss may contain thyroxine (T₄) or T₃ and should be considered as a cause of unexplained exogenous hyperthyroidism.

Effects of dehydroepiandrosterone sulphate (DHEAS) replacement on insulin action and quality of life in hypopituitary females: a double-blind, placebo-controlled study

OBJECTIVE

Addition of dehydroepiandrosterone sulphate (DHEAS) to standard pituitary replacement may improve quality of life and glucose metabolism. Conflicting results from the previous work probably relate to differences in populations studied and assessment techniques used. We examined the effects of DHEAS on insulin action and the quality of life in female patients with hypopituitary hypoadrenalism.

DESIGN

Randomized, double-blind, placebo-controlled, crossover design was used. Patients received either DHEAS 50 mg daily or placebo for 12 weeks.

PATIENTS

Fourteen hypopituitary females on stable standard replacement therapy and with low DHEAS were enrolled.

MEASUREMENTS

Insulin action by euglycaemic hyperinsulinaemic clamp and extensive quality of life parameters were assessed after each treatment.

RESULTS

Serum DHEAS (DHEAS 5·4 ± 0·8 vs placebo <0·8 ± 0·0 μm; P < 0·001) and androstenedione (DHEAS 4·1 ± 0·8 vs placebo 1·3 ± 0·2 nm; P < 0·05) rose to within the normal range after DHEAS 50 mg daily. There were no differences between treatments in testosterone, sex hormone-binding globulin (SHBG) or IGF-1. Quality of life measures were unchanged after DHEAS. There were no differences between treatments in fasting glucose, serum insulin, HbA1c or in insulin action (glucose infusion rates required to maintain euglycaemia; DHEAS 21·9 ± 2·5 vs placebo 24·5 ± 2·1 μmol/kg/min; P = 0·4). Triglyceride concentrations were lower following DHEAS (DHEAS 1·24 ± 0·18 vs placebo 1·41 ± 0·19 mm; P < 0·05) but other lipid parameters remained unchanged.

CONCLUSION

There were no differences compared with placebo in quality of life or insulin action after DHEAS replacement therapy for 12 weeks. These results do not provide evidence for the addition of DHEAS to standard hypopituitary replacement therapy.

Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis

The Joint British Diabetes Societies guidelines for the management of diabetic ketoacidosis (these do not cover Hyperosmolar Hyperglycaemic Syndrome) are available in full at: (i) http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/The-Management-of-Diabetic-Ketoacidosis-in-Adults; (ii)  http://www.diabetes.nhs.uk/publications_and_resources/reports_and_guidance; (iii) http://www.diabetologists-abcd.org.uk/JBDS_DKA_Management.pdf. This article summarizes the main changes from previous guidelines and discusses the rationale for the new recommendations. The key points are: Monitoring of the response to treatment (i) The method of choice for monitoring the response to treatment is bedside measurement of capillary blood ketones using a ketone meter. (ii) If blood ketone measurement is not available, venous pH and bicarbonate should be used in conjunction with bedside blood glucose monitoring to assess treatment response. (iii) Venous blood should be used rather than arterial (unless respiratory problems dictate otherwise) in blood gas analysers. (iv) Intermittent laboratory confirmation of pH, bicarbonate and electrolytes only. Insulin administration (i) Insulin should be infused intravenously at a weight-based fixed rate until the ketosis has resolved. (ii) When the blood glucose falls below 14 mmol/l, 10% glucose should be added to allow the fixed-rate insulin to be continued. (iii) If already taking, long-acting insulin analogues such as insulin glargine (Lantus(®), Sanofi Aventis, Guildford, Surry, UK) or insulin detemir (Levemir(®), Novo Nordisk, Crawley, West Sussex, UK.) should be continued in usual doses. Delivery of care (i) The diabetes specialist team should be involved as soon as possible. (ii) Patients should be nursed in areas where staff are experienced in the management of ketoacidosis.

Ten-year clinical follow-up of a cohort of 51 patients with macroprolactinemia establishes it as a benign variant

CONTEXT

Macroprolactinemia is a common finding in patients with hyperprolactinemia. There are no published long-term follow-up studies.

OBJECTIVE

The aim of this study was to describe findings after prolonged follow-up in a previously published cohort of patients with macroprolactinemia.

STUDY POPULATION

We studied 51 patients identified as having macroprolactinemia after polyethylene glycol precipitation.

DESIGN

Clinical assessment and serum prolactin assay were repeated in 51 patients with macroprolactinemia after a median follow-up of 9.9 yr (range, 9-11 yr).

RESULTS

Median age at presentation was 41 yr (range, 18-55 yr). Mean serum prolactin concentration at presentation was 1885 mU/liter, and after follow-up 1370 mU/liter. At follow-up, headache had been experienced in 12 patients (24%) and oligomenorrhea in five (10%). Galactorrhea was present in only two patients (4%). No visual deterioration was noted in 50 patients. One had a transient bitemporal hemianopia. No patients developed an autoimmune condition. Microadenoma had been identified in four patients at presentation with no new pituitary imaging abnormalities identified at follow-up.

CONCLUSIONS

During prolonged follow-up, no symptomatic progression was noted in any of our patients. This study suggests that patients with macroprolactinemia and normal concentrations of monomeric prolactin can be reassured, and extended endocrine review of such patients is not required.

Effect of feeding Mucuna pruriens on helminth parasite infestation in lambs

ETHNOPHARMACOLOGICAL RELEVANCE

Mucuna pruriens is a tropical legume anecdotally reputed to have anthelmintic properties. This study was conducted to examine the validity of such claims.

AIM OF THE STUDY

The aim of this study was to determine if ingestion of Mucuna seeds reduces helminth parasite infestation in lambs.

MATERIALS AND METHODS

Thirty-six Dorper x Katahdin ram lambs were assigned to three treatments, a cottonseed meal based control diet, a diet in which Mucuna replaced cottonseed meal and the control diet with levamisole (7.5mg/kg body weight) administration. All diets were isonitrogenous and isocaloric. The 12 lambs in each treatment were assigned randomly to 4 pens, each containing 3 lambs. Lambs were trickle infected three times per week by gavage with infectious Haemonchus contortus larvae (2000 larvae/lamb) for 3 weeks.

RESULTS

Levamisole treatment decreased fecal egg counts by 87% and abomasal worm counts by 83%. Mucuna intake did not statistically affect fecal egg counts or abomasal worm counts, though numerical (P>0.10) reductions of 7.4% and 18.1%, respectively were evident. Anemia indicators, feed intake, and lamb growth were unaffected by treatment.

CONCLUSIONS

Levamisole reduced the Haemonchus parasite burden in lambs significantly but feeding Mucuna reduced the burden by levels unlikely to eliminate the clinical effects of parasitism.

The effect of manipulation of basal pulsatile insulin on insulin action in Type 2 diabetes

AIM

Disordered insulin pulsatility is associated with insulin resistant states including Type 2 diabetes. However, whether abnormal basal insulin pulses play a role in the pathogenesis of insulin resistance or are simply an associated feature remains undetermined. We investigated this relationship further by studying the effect of overnight (10 h) pulsatile insulin infusion on subsequent insulin sensitivity.

METHODS

We studied 17 Type 2 diabetic patients who underwent one of two protocols. In protocol A (10 patients) on two separate nights we infused insulin 0.1 mU/kg/min either in a constant infusion or in pulses every 13 min. Octreotide (0.43 microg/kg/h) was given to suppress endogenous insulin secretion and physiological replacement of glucagon (30 ng/kg/h) administered. Insulin sensitivity was measured using a hyperinsulinaemic euglycaemic clamp (2 mU/kg/min) next morning. In protocol B (seven patients), we employed the same experimental procedure but used a basal insulin infusion rate of 0.09 mU/kg/min in 7-min or 13-min pulses.

RESULTS

Appropriate pulse patterns were confirmed in each protocol. In protocol A, after overnight infusions, glucose infusion rates required to maintain euglycaemia at steady state hyperinsulinaemia were similar (33.9 +/- 5.2 vs. 31.2 +/- 4.1 micromol/kg/min; P = NS). In protocol B, after overnight infusions the glucose infusion rates required during hyperinsulinaemia were significantly lower during 7-min pulses (39.9 +/- 5.7 vs. 44.7 +/- 5.6 micromol/kg/min; P < 0.05).

CONCLUSION

There was no demonstrable priming effect derived from overnight pulsatile insulin compared with constant insulin infusion on subsequent insulin sensitivity in Type 2 diabetic subjects. The failure of 7-min pulses to exhibit an advantageous effect over 13-min pulses raises questions about the natural frequency of basal insulin pulses and their biological effect.

Comparison of the priming effects of pulsatile and continuous insulin delivery on insulin action in man

Insulin is normally secreted in man in regular pulses every 5 to 15 minutes. Disordered pulsation has been demonstrated in several insulin-resistant states and it is unclear whether this represents a primary beta-cell defect contributing to impairment of peripheral insulin action or rather is a consequence of insulin resistance. Basal or near basal insulin administration by pulsatile infusion augments hypoglycemic effect and improves insulin-mediated glucose uptake compared with insulin by continuous infusion. To date no study has examined whether normal basal insulin pulsatility is required to preserve subsequent insulin sensitivity during hyperinsulinemia. We studied the effect of overnight pulsatile versus continuous basal insulin on a subsequent hyperinsulinemic euglycemic clamp. Nineteen normal volunteers (male:female ratio, 17:2; mean age +/- SEM, 26.1 +/- 2.3 years) were studied on 2 occasions each. Endogenous insulin secretion was inhibited by octreotide (0.43 microg kg(-1). h(-1)) and replaced overnight at 5.4 mU kg(-1). h(-1) either by continuous infusion or in 2-minute pulses every 13 minutes (n = 10) or every 7 minutes (n = 9). Glucagon was replaced at physiological concentration by continuous infusion (30 ng. kg(-1). h(-1)). Venous plasma glucose overnight was not significantly different between the pulsatile and continuous protocols. After discontinuing the overnight insulin infusion, insulin action was assessed during a hyperinsulinemic euglycemic clamp (1 mU kg(-1). h(-1)). Glucose infusion rates at steady-state during the hyperinsulinemic clamp were similar between continuous and both frequencies of pulsatile infusion (continuous 44.6 +/- 4.3 micromol. kg(-1). min(-1) v 13-minute pulsatile 41.7 +/- 5.9 micromol. kg(-1). min(-1), P =.27; continuous 34.6 +/- 2.5 micromol. kg(-1) min(-1) v 7-minute pulsatile 41.4 +/- 3.2 micromol. kg(-1). min(-1), P =.08). We conclude that overnight pulsatile compared with continuous insulin administration has no different effect on subsequent peripheral insulin-mediated glucose uptake. A priming effect cannot therefore explain the previously demonstrated association between endogenous insulin pulse frequency and peripheral insulin action.

Laboratory and clinical experience in 55 patients with macroprolactinemia identified by a simple polyethylene glycol precipitation method

PRL exists in different forms in human serum. The predominant form is little PRL (molecular mass 23 kDa) with smaller amounts of big PRL (molecular mass 50--60 kDa) and at times big big or macroprolactin (molecular mass 150--170 kDa). The frequency and clinical consequences of macroprolactinemia have not been clearly established, mainly because of difficulty in identifying these patients biochemically. This previously required the use of gel filtration chromatography, which could not be used routinely. Recently, a screening test using polyethylene glycol (PEG) has been used to identify macroprolactin in serum. Consequently, this study was designed to examine the use of PEG precipitation in the identification of patients with a predominance of macroprolactin and to establish the clinical characteristics of such a cohort. Over 12 months, 18,258 requests for serum PRL were received and of these 1225 patients had a serum PRL more than 700 mU/L. A total of 322 of these patients (26%) had a percentage recovery after PEG precipitation of less than 40%, thus indicating the presence of a predominance of macroprolactin. Fifty-five of these patients were referred for detailed clinical assessment. Symptoms typical of hyperprolactinemia were not common in this cohort. None had sustained amenorrhea and eight have had oligomenorrhea at age less than 40 yr. One had galactorrhea. All had pituitary imaging, and four had a microadenoma with none having a macroadenoma. PEG precipitation allows easy identification of macroprolactin in routine clinical practice. As the clinical consequences of this entity at this stage seem relatively benign, referral and intensive investigation of these patients may not be necessary. However, follow-up of a large cohort is required to ensure that the long-term outlook is likewise benign. This would have important implications for both patients and healthcare systems.

Comparison of heartworm antigen test kit performance in dogs having low heartworm burdens

Sensitivity and specificity of four in-clinic heartworm antigen test kits, AbboScreen (Abbott Laboratories), Snap PF (IDEXX Laboratories), Solo Step (HESKA Corporation), Witness (Synbiotics Corporation) and two heartworm antigen microwell plate assays, DiroCHEK (Synbiotics) and PetChek PF (IDEXX) were compared in a blinded study using serum or plasma drawn from 237 random source dogs, including 140 with necropsy-confirmed, low worm burden infections (minimum 1 worm, maximum 10, mean 2.3, median 3) and 97 confirmed heartworm-free at necropsy. In general, microwell format tests were more sensitive than membrane format tests and tests using ELISA technology were more sensitive than tests using lateral flow immunochromatographic technology. Percent sensitivity and specificity, respectively, were PetChek PF 76 and 97, DiroCHEK 71 and 94, SNAP PF 67 and 98, Solo Step 60 and 98, and AbboScreen 52 and 96. The Witness test protocol was changed by the manufacturer midway through the study, and the newer version of this test kit arrived containing a package insert alerting the user to a change in procedure, which purportedly resulted in improved sensitivity. PetChek was significantly more sensitive than all other tests except DiroCHEK and the new version of Witness. DiroCHEK was significantly more sensitive than all tests except PetCheck, SNAP and the new version of Witness. Snap was more sensitive than AbboScreen and the old version of Witness. Differences in specificity were not significant (P>0.05).

Seasonal prevalence of third-stage larvae of Dirofilaria immitis in mosquitoes from Florida and Louisiana

Heads of 109,597 mosquitoes collected during 1996 and 1997 from Gainesville, Florida (1996, n = 39,131; 1997, = 34,209), Bartow, Florida (1996, n = 12,000; 1997, n = 12,000), and Baton Rouge, Louisiana (1996, n = 12,257) were tested by a polymerase chain reaction and Southern hybridization-based test for the presence of third-stage larvae of the canine heartworm Dirofilaria immitis. Mosquito heads were pooled (1-200 heads) by month, locality, and species for testing. The test used was species specific for D. immitis and was capable of detecting DNA from a single larva in a pool of 200 mosquito heads. Specificity for the third larval stage was achieved by probing only mosquito heads. One or more D. immitis-infected mosquito heads were detected in each month of the year from Barrow in both 1996 and 1997. No infected mosquito heads were detected from Gainesville or Baton Rouge in December, January, February, or March. These results are in general agreement with previous sentinel dog and model prediction studies that showed heartworm transmission in the warm temperate Gulf coast region of the United States to be seasonal rather than continuous as previously believed.

Relationship between microfilaria count and sensitivity of the direct smear for diagnosis of canine dirofilariosis

Direct blood smear examination (using 0.05 ml of whole blood) detected 168 (80.9%) of 204 microfilaremic canine blood samples as determined by the modified Knott test for microfilariae (mff) of Dirofilaria immitis (using 1 ml of whole blood). Direct smear examination detected all of 134 microfilaremias greater than 50 mff ml(-1), but only 31 of 70 (44.3%) microfilaremias having less than 50 mff ml(-1). In a separate retrospective query of a database of 963 dogs with necropsy-confirmed heartworm infections, 834 (86.6%) were positive by the DiroCHEK heartworm antigen test, and 504 (52.3%) were microfilaremic by the modified Knott test. Only 2 (0.4%) of the microfilaremic dogs were DiroCHEK negative and another 18 (3.6%) were very weak positives. Although these microfilaremic dogs were not tested by direct smear, only one of the two DiroCHEK-negative and six of 18 weakly DiroCHEK-positive dogs had microfilaremias so low that a direct smear may have given a false negative result. Significant adverse reactions to either diethylcarbamazine or the macrolide endectocides have not been reported for microfilaremias less than 500 mff ml(-1), thus substitution of the direct smear for a concentration test for mff, such as the modified Knott test or membrane filtration, does not appear to increase the risk of an unexpected adverse reaction to heartworm prophylactic drugs. Such a substitution results in only a very slight decrease (on the order of 0.1%) in the overall sensitivity of heartworm screening, provided a test for mff is run concurrently with an antigen test. If a test for mff is the only screening test used, then substitution of a direct smear for a concentration test may decrease the sensitivity of heartworm screening by nearly 20%, depending on the prevalence of low level microfilaremias in the population of dogs tested.

Comparison of one week 0900 h serum cortisol, low and standard dose synacthen tests with a 4 to 6 week insulin hypoglycaemia test after pituitary surgery in assessing HPA axis

OBJECTIVE

To compare the use of 0900 h serum cortisol and both low and standard dose Synacthen tests, one week after pituitary surgery with an insulin hypoglycaemia test performed 4-6 weeks after surgery in assessing the integrity of the hypothalamic-pituitary-adrenal (HPA) axis.

DESIGN

0900 h basal serum cortisol was measured on days 6 and 7 after pituitary surgery (24 h off replacement hydrocortisone) followed by a low dose Synacthen test (1 microg intravenously) on day 6 and a standard dose Synacthen test (250 microg intramuscularly) on day 7. Three to 5 weeks later an insulin hypoglycaemia test was performed on all patients. Both low and standard dose Synacthen tests were performed on control subjects using an identical protocol.

SUBJECTS

Forty-two patients (21 male, 21 female), median age 49 years (range 23-73) who had pituitary surgery (Cushing's disease excluded). One patient had undergone repeat surgery for residual tumour and was studied following each operation. Sixteen healthy normal volunteers, median age 37 years (range 21-55).

MEASUREMENTS

Serum cortisol measured by radioimmunoassay.

RESULTS

Two standard deviations below the mean serum cortisol (logarithmic transformation) in the normal volunteers 30 minutes after low dose Synacthen (1 microg) was 496 nmol/l and after standard dose Synacthen (250 microg) was 504 nmol/l. A normal response was therefore taken as serum cortisol > 500 nmol/l at 30 minutes in both tests (using 496 and 504 nmol/l did not alter results). 0900 h serum cortisols 1 week after surgery were > 250 nmol/l in 31 patients and 29 of these had a normal response to hypoglycaemia (peak serum cortisol > 550 nmol/l). Of the remaining two patients, one had 0900 h serum cortisol on day 6 and 7 after surgery of 405 and 441 nmol/l with a peak serum cortisol response to hypoglycaemia of 451 nmol/l; the other patient had 0900 h serum cortisols of 416 and 251 nmol/l and a peak cortisol response to hypoglycaemia of 498 nmol/l. All eight patients who had a 0900 h serum cortisol < 100 nmol/l failed a subsequent insulin hypoglycaemia test. Seven discrepancies were noted between the low dose Synacthen test and the insulin hypoglycaemia test in the 41 patients who had both tests. In six of these, a subnormal response to low dose Synacthen was followed by a normal response to hypoglycaemia. Three discrepancies were noted between the standard dose Synacthen test and the insulin hypoglycaemia test in the 40 patients who had both tests. In all three cases a normal response to Synacthen was followed by a subnormal response to hypoglycaemia.

CONCLUSIONS

A 0900 h serum cortisol < 100 nmol/l (24 h off replacement hydrocortisone) indicated ACTH deficiency and need for lifelong steroid replacement. A 0900 h serum cortisol > 450 nmol/l one week after pituitary surgery is highly suggestive of a normal cortisol response to hypoglycaemia. A 0900 h serum cortisol between 250 and 450 nmol/l one week after pituitary surgery permits safe withdrawal of steroid therapy pending an insulin hypoglycaemia test 1 month after surgery. Patients with 0900 h serum cortisol between 100 and 250 nmol/l should continue replacement steroids until definitive testing. Low dose and standard dose Synacthen tests 1 week after pituitary surgery are unreliable and should not be used.

The insulin hypoglycaemia and overnight metyrapone tests in the assessment of the hypothalamic-pituitary-adrenal axis following pituitary surgery

OBJECTIVE

To compare the insulin hypoglycaemia test with the short overnight metyrapone test in the assessment of the hypothalamic-pituitary-adrenal (HPA) axis posthypophysectomy.

DESIGN

Prospective comparative study of the insulin hypoglycaemia test and the overnight metyrapone test in 32 patients 4-6 weeks after pituitary surgery.

SUBJECTS

Thirty-two patients with known pituitary disease. None with present or previous Cushing's syndrome.

OUTCOME MEASUREMENTS

Maximum serum cortisol achieved during insulin induced hypoglycaemia compared with 0900 hours serum 11-deoxycortisol level following a weight related oral dose of metyrapone at 0000 h.

RESULTS

One of the 32 patients required further surgery and was studied twice after each operation. Thirty-three results are therefore compared. Twenty-six of these had a normal cortisol response of 550 nmol/l or above leading to the cessation of replacement hydrocortisone. Six of these 26 patients however, failed the metyrapone test (11-deoxycortisol level less than 200 nmol/l). After 3-40 months (median 20 months) of follow-up off steroid therapy, no patient to date has displayed any clinical evidence of steroid deficiency. Of the seven patients who failed the insulin hypoglycaemia test, six also failed the metyrapone test.

CONCLUSIONS

The overnight metyrapone test identified more patients with possible ACTH deficiency than the insulin hypoglycaemia test. Further follow-up of these patients is required before a final judgement can be made as to whether more subtle but clinically relevant ACTH deficiency can be detected by the metyrapone test. Our clinical follow-up to date would not support this.

Seasonal transmission of equine cyathostomes in warm climates

Few studies investigating the seasonal transmission of equine cyathostomes have been done in warm climates. Two Australian studies used experimentally-infected plots to determine hatching, development and survival of free living stages of equine cyathostomes. Four studies in the southern United States used pasture larval counts, and in some instances tracer animals, to determine seasonal availability of infective cyathostome larvae on naturally-infected pastures. With the exception of the dry Australian tropics, a general pattern of peak transmission of cyathostomes during the cooler seasons of the year and minimal transmission during the warmest seasons was observed. Infective larvae and developing stages survived poorly in hot weather, although the rate of development was most rapid during that time. In contrast, infective larvae and developing stages survived well in cool weather, although the rate of development was slower. Adequate moisture was crucial to cyathostome transmission in warm climates, thus hot, dry weather effectively sterilized a pasture, whereas cool, moist weather was optimum for transmission. These data suggest that suppression of cyathostome egg output in feces of horses beginning shortly before the onset of cooler and/or more moist weather, and continued through the favorable period for development and survival of larvae on pasture - usually the autumn and winter should provide adequate control of these parasites. However, the efficacy of such seasonal control programs has yet to be adequately tested against that of traditional year round treatments.

Persistent efficacy of doramectin injectable against artificially induced infections with Cooperia punctata and Dictyocaulus viviparus in cattle

Three studies were conducted to evaluate the persistent efficacy of doramectin injectable solution against experimental challenges with infective larvae of Cooperia punctata and Dictyocaulus viviparus. In each study, four groups of ten randomly-assigned calves, negative for trichostrongyle-type eggs on fecal examination, were treated subcutaneously in the midline of the neck with saline (1 ml/50 kg) on Day 0 or doramectin (200 microg/kg = 1 ml/50 kg) on Day 0, 7, or 14. Two additional calves from the same pool of animals were randomly assigned as larval-viability monitors and received no treatment. On Days 14-28, approximately 1000 and 50 infective larvae of Cooperia spp. and D. viviparus, respectively, were administered daily by gavage to each animal in Groups T1-T4. On Day 28, the two larval-viability monitor calves were inoculated in a similar manner with a single dose of approximately 30000 and 2000 larvae of Cooperia spp. and D. viviparus, respectively. Equal numbers of calves from each treatment group were killed on Days 42-45, as well as the two viability monitor animals to enumerate worm numbers. A 2% or 5% aliquot of small intestinal contents and washings were examined for worm quantification and identification, while 100% of the lung recoveries were quantified and identified. For each study and across the three studies, geometric mean worm recoveries for each treatment group were calculated from the natural log transformed data (worm count + 1) and were used to estimate percentage reduction. In the three studies, doramectin injectable solution was 97.5% efficacious against lungworms for up to 28 days and was 99.8% efficacious in reducing infection resulting from challenge with infective larvae of C. punctata for at least 28 days post-treatment.

Substitution bias, rapid saturation, and the use of mtDNA for nematode systematics

Only relatively recently have researchers turned to molecular methods for nematode phylogeny reconstruction. Thus, we lack the extensive literature on evolutionary patterns and phylogenetic usefulness of different DNA regions for nematodes that exists for other taxa. Here, we examine the usefulness of mtDNA for nematode phylogeny reconstruction and provide data that can be used for a priori character weighting or for parameter specification in models of sequence evolution. We estimated the substitution pattern for the mitochondrial ND4 gene from intraspecific comparisons in four species of parasitic nematodes from the family Trichostrongylidae (38-50 sequences per species). The resulting pattern suggests a strong mutational bias toward A and T, and a lower transition/transversion ratio than is typically observed in other taxa. We also present information on the relative rates of substitution at first, second, and third codon positions and on relative rates of saturation of different types of substitutions in comparisons ranging from intraspecific to interordinal. Silent sites saturate extremely quickly, presumably owing to the substitution bias and, perhaps, to an accelerated mutation rate. Results emphasize the importance of using only the most closely related sequences in order to infer patterns of substitution accurately for nematodes or for other taxa having strongly composition-biased DNA. ND4 also shows high amino acid polymorphism at both the intra- and interspecific levels, and in higher level comparisons, there is evidence of saturation at variable amino acid sites. In general, we recommend using mtDNA coding genes only for phylogenetics of relatively closely related nematode species and, even then, using only nonsynonymous substitutions and the more conserved mitochondrial genes (e.g., cytochrome oxidases). On the other hand, the high substitution rate in genes such as ND4 should make them excellent for population genetics studies, identifying cryptic species, and resolving relationships among closely related congeners when other markers show insufficient variation.

The prevalence of Fasciola hepatica in its snail intermediate host determined by DNA probe assay

Accurate snail intermediate host infection prevalence data have the potential to be extremely useful in determining seasonal transmission dynamics of Fasciola hepatica. Because the microscopic techniques currently used lack the sensitivity and specificity necessary to obtain meaningful infection prevalence data, we developed a highly accurate and efficient DNA probe assay. The assay has a sensitivity of 100%, a specificity of > 99%, easily detects a single miracidia and does not cross-hybridize with DNA of Fascioloides magna, Paramphistomum liorchis or Heterobilharzia americana, trematodes that share the same intermediate host and enzootic range as Fasciola hepatica. Using this assay, we determined the prevalence of F. hepatica in its snail intermediate host, Fossaria cubensis, during the second year of a 2-year study on the epizootiology of Fasciola hepatica in Florida. The overall infection prevalence of snails assayed in this study (n = 5246) was 1.5% and ranged from 0.1% to 3.1% for individual cattle ranches. Additionally, infection prevalence differed significantly for successive size groupings of snails, varying from 0% for 1-mm snails to 18.5% for 9- and 10-mm snails. The accuracy and efficiency of the DNA probe assay reported here for determining snail infection prevalence offers an inexpensive alternative to tracer animal studies for determining the epizootiology of F. hepatica.

Haemonchus placei and Haemonchus contortus are distinct species based on mtDNA evidence

Debates continue over the extent to which the parasitic trichostrongylids Haemonchus placei and Haemonchus contortus hybridise in nature, and whether they deserve species status. Mitochondrial ND4 gene sequences from individuals of each putative species collected from populations around the United States indicate that the two species are highly differentiated at the mtDNA level. Furthermore, there was no evidence of introgressive hybridisation occurring in wild populations.

Monitoring Babesia bovis infections in cattle by using PCR-based tests

The sensitivity and specificity of PCR tests based on the small-subunit rRNA gene sequence of Babesia bovis were compared in a blind study of experimentally infected cattle with the corresponding parameters of the complement fixation (CF) test currently used in the United States to screen for bovine babesiosis. Cattle were experimentally infected with a single inoculum of a cloned laboratory strain of B. bovis. Blood samples were collected and tested over a period covering from the day of infection to 10 months postinfection. The level of parasitemia (percent infected erythrocytes) present in each sample was estimated from test results and was plotted as a function of time postinfection. These data are the first describing the course of infection by methods capable of detecting parasitemias in the range of 10(-7)%, which frequently occur in the carrier state. Parasitemias in the samples tested strongly influenced the sensitivity and negative predictive value of the PCR-based tests which varied with time postinfection. The average sensitivities of the three PCR-based tests for B. bovis ranged from 58 to 70% for a single determination, while the sensitivity of the CF test was only 6%. Both PCR-based and CF tests for B. bovis had high specificity values ranging from 96 to 100%.

Host movement and the genetic structure of populations of parasitic nematodes

Mitochondrial DNA (mtDNA) sequence data were used to compare the population genetic structures of five species of parasitic nematodes from three different hosts: Ostertagia ostertagi and Haemonchus placei from cattle, H. contortus and Teladorsagia circumcincta from sheep, and Mazamastrongylus odocoilei from white-tailed deer. The parasites of sheep and cattle showed a pattern consistent with high gene flow among populations. The parasite of deer showed a pattern of substantial population subdivision and isolation by distance. It appears that host movement is an important determinant of population genetic structure in these nematodes. High gene flow in the parasites of livestock also indicates great opportunity for the spread of rare alleles that confer resistance to anthelmintic drugs. All species, including the parasite of deer, had unusually high within-population diversities (averages of 0.019-0.027 substitutions per site between pairs of individuals from the same population). Large effective population sizes (Ne), perhaps in combination with rapid mtDNA evolution, appear to be the most likely explanation for these high within-population diversities.

A repetitive DNA probe for the sensitive detection of Fasciola hepatica infected snails

Epizootiologic studies on F. hepatica frequently use microscopic techniques for the detection of infected snails, however, the poor efficiency, sensitivity, and specificity associated with these techniques limit their usefulness. A DNA-based test for the identification of snails infected with larval stages of F. hepatica would solve these problems and enable a level of detection accuracy previously unavailable. We have cloned and sequenced a 124 bp fragment of repetitive DNA from F. hepatica which hybridizes specifically with DNA of F. hepatica but not with DNA of its snail intermediate hosts Fossaria cubensis and Pseudosuccinea columella, or with DNA of Fascioloides magna and Paramphistomum liorchis, ruminant trematodes which share the same intermediate host and same enzootic range as F. hepatica. Using this 124 bp fragment as a probe, infection in snails was detected immediately following miracidial penetration, thus a sensitivity equivalent to the minimum biologic unit of the parasite was achieved. This 124 bp repeated sequence belongs to a large family of 124 bp repeats that share a high level of sequence identity and constitute approximately 15% of the F. hepatica genome. We also report here the development of a quick and inexpensive DNA extraction protocol for use in field-collected snails. Thus, we have developed both a highly sensitive and specific DNA probe and a means to use the probe in a large epizootiologic study of F. hepatica where thousands of field-collected snails need to be assayed for infection.

World Association for the Advancement of Veterinary Parasitology (W.A.A.V.P.) guidelines for evaluating the efficacy of anthelmintics for dogs and cats

Guidelines have been designed to assist in the planning, operation and interpretation of studies for the assessment of the efficacy of drugs against helminth parasites of dogs and cats. The advantages, disadvantages and application of critical and controlled tests are presented. Information is also provided on the selection of animals, housing, feeding, dose-titration, confirmatory and clinical trials, record keeping and necropsy procedures. These guidelines should assist both investigators and registration authorities involved in the evaluation of anthelmintics to employ comparable and standard procedures and will have the added benefit of minimising the numbers of animals needed for such tests.

Efficacy of injectable abamectin against gastrointestinal tract nematodes and lungworms of cattle

Efficacy of abamectin against gastrointestinal tract nematodes and lungworms of cattle was determined in 4 experiments. The first 2 experiments were controlled trials in which efficacy was determined at necropsy in calves with either experimentally induced (n = 14) or naturally acquired (n = 16) infections. Half the calves in each experiment were treated with abamectin (200 micrograms/kg of body weight, SC), and half were left untreated as controls. Efficacy was > 99% against adult stages of Dictyocaulus viviparus, Haemonchus placei, Ostertagia ostertagi, Trichostrongylus axei, Cooperia punctata, Trichuris discolor, and C oncophora, and was 92.4% against Nematodirus helvetianus. The second 2 experiments were clinical trials in which efficacy was determined by fecal egg count reduction in naturally infected yearling heifers (n = 75) or 2-year-old heifers (n = 75). Within replicates of 5, 4 heifers were assigned at random to treatment with 200 micrograms of abamectin/kg and 1 was left untreated as a control. Abamectin was 100% effective in eliminating strongylate nematode eggs from the feces of these heifers. In all experiments, adverse reactions were limited to small, clinically unimportant injection site swellings in 29% of abamectin-treated calves. Abamectin was judged to be safe and effective in these trials.

Genetic structure of populations of Ostertagia ostertagi

Most genetic work to distinguish strains of parasitic helminths focuses on searching for genetic markers to correlate with phenotypes of interest, but in this study genetic diversity among individual Ostertagia ostertagi adults is partitioned into components within and between populations. Restriction fragment polymorphism data on mitochondrial DNA from ten individual worms from each of five different parasite populations are analyzed. Three of these populations are characterized by arrested larval development (hypobiosis) over the summer months, and the other two by hypobiosis over the winter months. Sequence divergence is scored by the presence or absence of 37 different restriction sites. Although the populations are genetically differentiated with respect to the timing of hypobiosis, greater than 98% of the total mitochondrial DNA sequence diversity is partitioned within a single population, and the geographic distribution of individual mitochondrial DNA haplotypes suggests high gene flow among populations. Further, estimates of within-population mitochondrial DNA diversity are five to ten times greater in O. ostertagi than typical estimates reported for species in other taxa.

Cloning and characterization of the ribosomal RNA gene repeat from Ostertagia ostertagi

Clones of the rRNA genes of Ostertagia ostertagi were selected from a library prepared from the genomic DNA of adult worms of strain LA-2. A 13.4-kb insert in a clone, lambda OOR78, is comprised of one complete 7.5-kb rDNA unit and portions of two adjacent units. The rDNA unit is directly repeated in a head-to-tail fashion and represents approximately 0.9% of the total genomic DNA. This repeating unit appears to be the only long tandemly repeated sequence in the genome. Restriction enzyme recognition sites in the rDNAs of four strains of O. ostertagi were fully conserved with the exception of one PstI site present in the large rRNA gene which was absent from a proportion of the genes of the LA-2 strain. The rDNA of O. ostertagi is more similar to that of Caenorhabditis elegans in unit length and arrangement than to parasitic helminths previously examined.

Evaluation of heartworm immunodiagnostic tests

In this report, the use of appropriate statistical methods for the evaluation of heartworm immunodiagnostic tests is discussed. The evaluation of these tests is complicated by factors causing variation in sensitivity, specificity, accuracy, and predictive values of positive and negative test results. The primary sources of inconsistency are variation in the prevalence of heartworm infection among populations of dogs and the sensitivity of immunodiagnostic tests to various categories of heartworm infections (ie, patent, immune-mediated occult, unisex occult, and immature occult). Sample size (ie, number of dogs tested) affects the confidence limit values of sensitivity and specificity. At least 100 dogs should be used in each testing group (infected and uninfected) to generate values of sensitivity or specificity within reasonably narrow confidence limits. Use of more than 200 dogs in each testing group contributes little to further narrowing of confidence limits. The selection of appropriate statistical tests for comparison of tests or comparison of the sensitivity or specificity of a single diagnostic test to various categories of heartworm infections is critical. The McNemar paired chi 2 test is appropriate for comparison of diagnostic tests, but it must be done by use of duplicate sera from each animal. A chi 2 test of independence, or, in the case of a small sample size, the Fisher exact test, is appropriate for comparing the sensitivity or specificity of a single diagnostic test to various categories of heartworm infection.

Seasonal transmission of Fasciola hepatica in north central Florida (U.S.A.)

To assess seasonal transmission of Fasciola hepatica 37 groups of fluke-free tracer sheep, one group of four sheep each month in succession, grazed an infected pasture in north central Florida (U.S.A.) from June 1984 to June 1987. At the end of each month, tracers were moved to a fluke-free barn for 2 months, then necropsied and flukes counted. Fluke transmission mostly occurred during the first half of the year, with peak transmission from February to April. No transmission occurred during the warm summer months, having ceased in either May or June of each year to begin again in late autumn or early winter (November-January).

The development of an enzyme-linked immunosorbent assay for Trypanosoma vivax and its use in a seroepidemiological survey of the Eastern Caribbean Basin

An enzyme-linked immunosorbent assay (ELISA) for IgG antibodies against a South American (New World) strain of Trypanosoma vivax was developed and used for mass screening of cattle from 20 islands in the Eastern Caribbean Basin. The sensitivity and specificity of antigens prepared from a bovine-derived field strain and a murine-adapted laboratory strain of T. vivax, both of New World origin, were compared using an indirect fluorescent antibody (IFA) test, and an antigen prepared from the murine-adapted strain was subsequently used to develop an ELISA test. The results of the ELISA test were then compared with the results of a concurrently run IFA test. There was no cross-reactivity with either test using serum from a Trypanosoma theileri-infected cow. Both tests were weakly cross-reactive with sera from a T. brucei-infected steer, and the IFA test was moderately cross-reactive with several serum samples from a T. evansi-infected steer. For bovine sera collected from herds on islands in the Eastern Caribbean region, only five of 640 tested positive with the ELISA test. Thirty five of 653 sera tested were positive by IFA although the fluorescence elicited was weak as compared to that elicited by sera from known infected animals. Sera collected from 27 cattle in a region known to be free of T. vivax (OH, U.S.A) were negative with the ELISA test, whereas seven of 30 sera from a herd in French Guiana known to be infected with T. vivax were positive.(ABSTRACT TRUNCATED AT 250 WORDS)

Distribution of Onchocerca spp. microfilariae in the dermis of cattle

A grid was drawn on a lateral half of 10 hides, from cattle infected with both Onchocerca gutturosa and Onchocerca lienalis, which were obtained from an abattoir in central Florida. Paired 7-mm diameter skin cores were taken from 24 grid sites on each hide and microfilariae (mff) extracted to determine their distribution. The only consistent pattern distribution was that mff were recovered from all 10 hides at four sample sites along the ventral midline near the umbilicus. Microfilariae were also frequently found in large numbers along the dorsal cervical midline and in the region of the tarsal and carpal-metacarpal joints.

Onchocerca gutturosa and Onchocerca lienalis in cattle: variation in length of microfilariae by site of recovery

Dermal microfilariae recovered from specimens obtained from umbilical and cervical sites of cattle infected with adult Onchocerca gutturosa alone or with adults of O gutturosa and O lienalis were measured and compared with uterine microfilariae obtained directly from gravid female worms of each species. Uterine microfilariae of O gutturosa were longer than dermal microfilariae obtained from cattle harboring only adults of O gutturosa. Dermal microfilariae were recovered from umbilical and cervical sites in these cattle. Those found at the cervical site had lengths equal to or greater than lengths of microfilariae recovered from the umbilical site. There was a significant (P less than 0.0001) shift in length across populations of microfilariae of O gutturosa from various sites in its bovine host, with a progressive decrease in length between microfilariae recovered from the worm's uterus, microfilariae from the cervical dermis, and microfilariae from the umbilical dermis, respectively. A similar direct comparison was not possible for microfilariae of O lienalis, because none of the cattle was infected with only adult worms of this species. In an indirect comparison, microfilariae of O lienalis were identified at the umbilicus, but their presence in the cervical region could not be determined unequivocally because of confounding of microfilariae length by concurrent infection with O gutturosa. Uterine microfilariae from O lienalis were longer than uterine microfilariae of O gutturosa, although a degree of overlap in the range of measurements existed between species.

Efficacy of febantel paste against naturally acquired gastrointestinal nematodes of cattle

Twenty calves with naturally acquired gastrointestinal nematode infections were assigned to 10 replicates of 2 calves each and were treated with febantel paste (5 mg/kg of body weight, PO) or an equivalent volume of paste vehicle (control calves). Adverse reactions were not observed after febantel treatment. At necropsy, gastrointestinal nematode counts in febantel-treated calves, compared with control calves, were reduced by over 99% for all major species except Trichuris discolor, counts of which were reduced by only 69%. Counts of gastrointestinal nematode eggs in feces of febantel-treated calves were reduced by 100% after treatment.

Possible association between Dirofilaria tenuis infections in humans and its prevalence in raccoons in Florida

A study was undertaken to determine the prevalence of Dirofilaria tenuis in raccoons from subtropical southern Florida as compared to the northern part of the state. The results indicate that D. tenuis is more prevalent in southern Florida and suggest that this might be why humans suffer from more D. tenuis infections in southern Florida than in other parts of the state.

Heterologous resistance to Fasciola hepatica conferred upon rats by passive transfer of serum from different breeds of sheep

Two experiments compared the protection against oral challenge with 20 metacercariae of Fasciola hepatica conferred on rats by intraperitoneal injection of serum from three breeds of sheep infected with F. hepatica (Barbados Blackbelly, St. Croix, Florida Native). Experiment 1 used serum from sheep 5-6 months of age following two infections of 250 metacercariae each, while Experiment 2 utilized serum collected from the same sheep at 10-11 months of age following either a primary (first exposure) or challenge (after two previous exposures of 250 metacercariae each) infection with 500 metacercariae. Similar numbers of flukes were recovered from rats given either immune or nonimmune (control) serum from each breed of sheep in Experiment 1. In Experiment 2, rats given serum from infected St. Croix sheep had significantly fewer flukes than rats given either control or immune serum from Barbados Blackbelly or Florida Native sheep. There was no significant correlation of fluke counts between individual serum donors (sheep) and serum recipients (rats).

Onchocerca gutturosa and Onchocerca lienalis in cattle: effect of age, sex, and origin on prevalence of onchocerciasis in subtropical and temperate regions of Florida and Georgia

Evaluation of 845 cattle from Florida and Georgia for onchocerciasis indicated a significantly higher prevalence of infection with Onchocerca gutturosa and a significantly lower prevalence of infection with Onchocerca lienalis in the southern portion of Florida (subtropical region) than in the northern portion of Florida or in Georgia (temperature region). In all regions, prevalence of infection with O gutturosa was significantly higher than infection with O lienalis. In the temperate region, bulls were infected more often with O lienalis than were cows. Other sex-related differences in infection with either filariid was not found. Prevalence of infection with O lienalis was similar between age groups in all regions. Rates of infection with O gutturosa differed between age groups within and between subtropical and temperate regions. Examination of cervical and umbilical skin specimens for microfilariae detected an additional 6.6% of infected animals that had not been found by examination for adult worms. However, microfilariae were not found in 21.4% of animals that were positive for adult worms.

Epidemiology and control of parasites in warm climates

The kind of parasites a horse acquires depends upon its environment. Because patterns of transmission vary greatly with climate and management, no one worming program has universal applications. This article discusses epidemiology and control of equine parasites in the southern United States, where climates vary from warm temperate to subtropical and from humid in the southeast to arid in the southwest.

Efficacy of an albendazole feed formulation against bovine gastrointestinal nematodes including arrested larvae of Ostertagia ostertagi

The efficacy of an albendazole feed premix formulation was compared with that of an albendazole drench suspension for control of gastrointestinal nematodes in 31 beef cattle. The premix (11 cattle) and drench suspension (9 cattle) were found to have similar efficacies at a dosage of 7.5 mg/kg of body weight. When compared with controls (11 cattle), both formulations caused significant (P less than 0.05) reductions in worm counts with an efficacy of 98% or greater against adult Haemonchus placei, Ostertagia ostertagi, Trichostrongylus axei, Cooperia punctata, and C pectinata. There was no significant effect against arrested 4th-stage larvae of O ostertagi. Adverse effects of albendazole treatment were not observed, and the premix formulation was readily consumed by cattle.

Effect of ivermectin on murine mites

Two SC injections of ivermectin (200 micrograms/kg of body weight), given one week apart, safely and effectively eliminated mite infestations (Myocoptes musculinus and Myobia musculi) from laboratory mice. When one 200 micrograms/kg or one 100 micrograms/kg injection of ivermectin was given to the mice, mite infestations were reduced temporarily.

Efficacy and safety of clorsulon used concurrently with ivermectin for control of Fasciola hepatica in Florida beef cattle

The safety and anthelmintic efficacy of clorsulon (7 mg/kg of body weight, orally) given concurrently with ivermectin (0.2 mg/kg, subcutaneously) for control of Fasciola hepatica were evaluated in 75 crossbred beef cattle. Twenty-three control animals were given only ivermectin. Fluke egg counts were significantly lower (P less than 0.0001) in clorsulon-treated animals by day 14 after treatment than before treatment (base line) and were significantly lower (P less than 0.005) after treatment in clorsulon-treated animals than in controls. There was no significant change in fluke egg counts of controls after treatment. The efficacy of clorsulon in reducing F hepatica egg counts was 99%. Clorsulon showed poor efficacy against paramphistomes. Adverse reactions were not observed.