Long-term bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study

BACKGROUND

Severe grief is highly distressing and prevalent up to 1 year post-death among people bereaved during the first wave of COVID-19, but no study has assessed changes in grief severity beyond this timeframe.

AIM

Understand the trajectory of grief during the pandemic by reassessing grief symptoms in our original cohort 12-18 months post-death.

DESIGN

Prospective matched cohort study.

SETTINGS/PARTICIPANTS

Family members of decedents who died in an acute care hospital between November 1, 2019 and August 31, 2020 in Ottawa, Canada. Family members of patients who died of COVID (COVID +ve) were matched 2:1 with those who died of non-COVID illness (COVID -ve) during pandemic wave 1 or immediately prior to its onset (pre-COVID). Grief was assessed using the Inventory of Complicated Grief (ICG).

RESULTS

Follow-up assessment was completed by 92% (111/121) of family members in the initial cohort. Mean ICG score on the 12-18-month assessment was 19.9 (SD = 11.8), and severe grief (ICG > 25) was present in 28.8% of participants. One-third (33.3%) had either a persistently high (>25) or worsening ICG score (⩾4-point increase between assessments). Using a modified Poisson regression analysis, persistently high or worsening ICG scores were associated with endotracheal intubation in the deceased, but not cause of death (COVID +ve, COVID -ve, pre-COVID) or physical presence of the family member in the final 48 h of life.

CONCLUSIONS

Severe grief is a substantial source of psychological morbidity in the wake of the COVID-19 pandemic, persisting more than a year post-death. Our findings highlight an acute need for effective and scalable means of addressing severe grief.

Comorbidities, symptoms and end-of-life medication use in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada

OBJECTIVE

To compare comorbidities, symptoms and end-of-life (EoL) palliative medication (antisecretories, opioids, antipsychotics and sedatives) use among decedents before and during the COVID-19 pandemic.

DESIGN

In a retrospective cohort study, decedent records in three acute care hospitals were abstracted, generating a prepandemic (November 2019-February 2020) group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one without (COVID-ve) and one with COVID-19 infection (COVID+ve). Control group decedents were matched 2:1 on age, sex and care service (medicine/intensive care unit (ICU)) with COVID+ve decedents.

SETTING

Three regional acute care teaching hospitals in Ottawa, Canada PARTICIPANTS: Decedents (N=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170).

MAIN OUTCOME MEASURES

Data were abstracted regarding demographics, admission comorbidities and symptoms, and EoL medication use; opioid doses were standardised to parenteral morphine equivalent daily dose (MEDD), and the predictors of upper quartile MEDD in the last 24 hours of life were examined in multivariable logistic regression with adjusted ORs (aORs) and 95% CIs.

RESULTS

The prevalence of dementia (41% vs 28% and 26%, p=0.03), breathlessness (63.5% vs 42% and 47%, p<0.01), cough (40% vs 27% and 19%, p<0.01) and fever (54% vs 9% and 13.5%) was higher in COVID+ve versus pre-COVID and COVID-ve groups, respectively. The median (IQR) of MEDD over the last 72 hours of life was 16.7 (9-36.5) vs 13.5 (5.7-21.8) and 10.5 (5.3-23.8) for COVID+ve versus pre-COVID and COVID-ve groups, respectively, (p=0.007). Male sex, COVID+ve grouping, ICU death and high-flow nasal cannula use predicted upper quartile MEDD dose, aORs (95% CIs): 1.84 (1.05 to 3.22), 2.62 (1.29 to 5.3), 5.14 (2.47 to 10.7) and 1.93 (1.05 to 3.52), respectively. COVID+ve group decedents used highest lorazepam and propofol doses.

CONCLUSIONS

COVID-19 decedents, particularly those in ICU, required higher EoL opioid and sedating medication doses than matched prepandemic or intrapandemic controls. These findings should inform and guide clinical practice.

Experience of introducing an electronic health records station in an objective structured clinical examination to evaluate medical students’ communication skills in Canada: a descriptive study

PURPOSE

There is limited literature related to the assessment of electronic medical record (EMR)-related competencies. To address this gap, this study explored the feasibility of an EMR objective structured clinical examination (OSCE) station to evaluate medical students’ communication skills by psychometric analyses and standardized patients’ (SPs) perspectives on EMR use in an OSCE.

METHODS

An OSCE station that incorporated the use of an EMR was developed and pilot-tested in March 2020. Students’ communication skills were assessed by SPs and physician examiners. Students’ scores were compared between the EMR station and 9 other stations. A psychometric analysis, including item total correlation, was done. SPs participated in a post-OSCE focus group to discuss their perception of EMRs’ effect on communication.

RESULTS

Ninety-nine 3rd-year medical students participated in a 10-station OSCE that included the use of the EMR station. The EMR station had an acceptable item total correlation (0.217). Students who leveraged graphical displays in counseling received higher OSCE station scores from the SPs (P=0.041). The thematic analysis of SPs’ perceptions of students’ EMR use from the focus group revealed the following domains of themes: technology, communication, case design, ownership of health information, and timing of EMR usage.

CONCLUSION

This study demonstrated the feasibility of incorporating EMR in assessing learner communication skills in an OSCE. The EMR station had acceptable psychometric characteristics. Some medical students were able to efficiently use the EMRs as an aid in patient counseling. Teaching students how to be patient-centered even in the presence of technology may promote engagement.

Bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study

BACKGROUND

The COVID-19 pandemic has caused millions of deaths worldwide, leading to symptoms of grief among the bereaved. Neither the burden of severe grief nor its predictors are fully known within the context of the pandemic.

AIM

To determine the prevalence and predictors of severe grief in family members who were bereaved early in the COVID-19 pandemic.

DESIGN

Prospective, matched cohort study.

SETTING/PARTICIPANTS

Family members of people who died in an acute hospital in Ottawa, Canada between November 1, 2019 and August 31, 2020. We matched relatives of patients who died of COVID (COVID +ve) with those who died of non-COVID illness either during wave 1 of the pandemic (COVID -ve) or immediately prior to its onset (pre-COVID). We abstracted decedents' medical records, contacted family members >6 months post loss, and assessed grief symptoms using the Inventory of Complicated Grief-revised.

RESULTS

We abstracted data for 425 decedents (85 COVID +ve, 170 COVID -ve, and 170 pre-COVID), and 110 of 165 contacted family members (67%) consented to participate. Pre-COVID family members were physically present more in the last 48 h of life; the COVID +ve cohort were more present virtually. Overall, 35 family members (28.9%) had severe grief symptoms, and the prevalence was similar among the cohorts (p = 0.91). Grief severity was not correlated with demographic factors, physical presence in the final 48 h of life, intubation, or relationship with the deceased.

CONCLUSION

Severe grief is common among family members bereaved during the COVID-19 pandemic, regardless of the cause or circumstances of death, and even if their loss took place before the onset of the pandemic. This suggests that aspects of the pandemic itself contribute to severe grief, and factors that normally mitigate grief may not be as effective.

Comparative end-of-life communication and support in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada

OBJECTIVE

To compare end-of-life in-person family presence, patient-family communication and healthcare team-family communication encounters in hospitalised decedents before and during the COVID-19 pandemic.

DESIGN

In a regional multicentre retrospective cohort study, electronic health record data were abstracted for a prepandemic group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one COVID-19 free (COVID-ve) and one with COVID-19 infection (COVID+ve). Pre-COVID and COVID-ve groups were matched 2:1 (age, sex and care service) with the COVID+ve group.

SETTING

One quaternary and two tertiary adult, acute care hospitals in Ottawa, Canada.

PARTICIPANTS

Decedents (n=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170).

MAIN OUTCOME MEASURES

End-of-life (last 48 hours) in-person family presence and virtual (video) patient-family communication, and end-of-life (last 5 days) virtual team-family communication encounter occurrences were examined using logistic regression with ORs and 95% CIs. End-of-life (last 5 days) rates of in-person and telephone team-family communication encounters were examined using mixed-effects negative binomial models with incidence rate ratios (IRRs) and 95% CIs.

RESULTS

End-of-life in-person family presence decreased progressively across pre-COVID (90.6%), COVID-ve (79.4%) and COVID+ve (47.1%) groups: adjusted ORs=0.38 (0.2-0.73) and 0.09 (0.04-0.17) for COVID-ve and COVID+ve groups, respectively. COVID-ve and COVID+ve groups had reduced in-person but increased telephone team-family communication encounters: IRRs=0.76 (0.64-0.9) and 0.61 (0.47-0.79) for in-person, and IRRs=2.6 (2.1-3.3) and 4.8 (3.7-6.1) for telephone communications, respectively. Virtual team-family communication encounters occurred in 17/85 (20%) and 10/170 (5.9%) of the COVID+ve and COVID-ve groups, respectively: adjusted OR=3.68 (1.51-8.95).

CONCLUSIONS

In hospitalised COVID-19 pandemic wave 1 decedents, in-person family presence and in-person team-family communication encounters decreased at end of life, particularly in the COVID+ve group; virtual modalities were adopted for communication, and telephone use increased in team-family communication encounters. The implications of these communication changes for the patient, family and healthcare team warrant further study.

One Health surveillance of West Nile and Usutu viruses: a repeated cross-sectional study exploring seroprevalence and endemicity in Southern France, 2016 to 2020

BackgroundWest Nile virus (WNV) and Usutu virus (USUV), two closely related flaviviruses, mainly follow an enzootic cycle involving mosquitoes and birds, but also infect humans and other mammals. Since 2010, their epidemiological situation may have shifted from irregular epidemics to endemicity in several European regions; this requires confirmation, as it could have implications for risk assessment and surveillance strategies.AimTo explore the seroprevalence in animals and humans and potential endemicity of WNV and USUV in Southern France, given a long history of WNV outbreaks and the only severe human USUV case in France in this region.MethodsWe evaluated the prevalence of WNV and USUV in a repeated cross-sectional study by serological and molecular analyses of human, dog, horse, bird and mosquito samples in the Camargue area, including the city of Montpellier, between 2016 and 2020.ResultsWe observed the active transmission of both viruses and higher USUV prevalence in humans, dogs, birds and mosquitoes, while WNV prevalence was higher in horses. In 500 human samples, 15 were positive for USUV and 6 for WNV. Genetic data showed that the same lineages, WNV lineage 1a and USUV lineage Africa 3, were found in mosquitoes in 2015, 2018 and 2020.ConclusionThese findings support existing literature suggesting endemisation in the study region and contribute to a better understanding of USUV and WNV circulation in Southern France. Our study underlines the importance of a One Health approach for the surveillance of these viruses.

Equine Umbilical Cord Serum Composition and Its Healing Effects in Equine Corneal Ulceration

Background

Human autologous serum (AS) and umbilical cord serum (UCS) both contain growth and neurotrophic factors that promote corneal healing.

Aim

Our objectives were to compare equine AS and UCS cytokine and growth factor profiles and to assess the safety and clinical feasibility of the therapeutic use of UCS eye drops in cases of spontaneous complex ulcers.

Study Design

Prospective clinical trial.

Methods

Vitamin A insulin growth factor, platelet-derived growth factor-BB, transforming growth factor (TGF)-β1 (enzyme-linked immunosorbent assay), interleukin (IL)-1β, IL-6, interferon-γ, and monocyte chemoattractant protein 1 concentrations were determined in 10 AS collected from different horses and 10 UCS sampled at delivery. Six client-owned horses presenting with complex non-healing corneal defects of >5 mm² were included in a clinical trial and treated with conventional therapy and conditioned UCS drops for 8–15 days. Ulcer surface and time to complete epithelialization were recorded.

Results

Median concentrations of vitamin A, insulin growth factor, and platelet-derived growth factor-BB were not significantly different in AS compared with UCS (respectively, 14.5 vs. 12.05 μg/ml; 107.8 vs. 107.3 pg/ml; and 369.1 vs. 924.2 pg/ml). TGF-β1 median concentration in UCS was significantly higher than in AS (3,245 vs. 2571pg/ml) (p = 0.04). IL-1β, IL-6, interferon-γ, and monocyte chemoattractant protein 1 concentrations were variable in AS and undetectable in UCS. The corneal median ulcerative area was 37.2 mm² (6.28–57.14 mm²) and had a duration of 4–186 days (median 19 days). All lesions healed within 13–42 days (median 17 days). No adverse effects nor recurrences within 1 month were noticed.

Limitations

The sample size was small. Spontaneous corneal epithelial defects presented with variable clinical characteristics. There were no age-matched control horses to assess corneal healing time and rate.

Conclusion and Clinical Significance

Equine UCS may be beneficial, as it contains no pro-inflammatory cytokines and a greater concentration of TGF-β1 compared with AS. Topical UCS appears safe and may potentially be used as adjunctive therapy for equine complex non-healing ulcers.

Mesenchymal stem cell transplantation into the spinal cord of healthy adult horses undergoing cervical ventral interbody fusion

OBJECTIVE

To determine the feasibility of umbilical cord-derived mesenchymal stem cell (UC-MSC) transplantation into the cervical spinal cord of horses by using fluoroscopy with or without endoscopic guidance and to evaluate the neurological signs and tissue reaction after injection.

STUDY DESIGN

Experimental study.

ANIMALS

Eight healthy adult horses with no clinical signs of neurological disease.

METHODS

After cervical ventral interbody fusion (CVIF), ten million fluorescently labeled allogeneic UC-MSC were injected into the spinal cord under endoscopic and fluoroscopic guidance (n = 5) or fluoroscopic guidance only (n = 3). Postoperative neurological examinations were performed, and horses were humanely killed 48 hours (n = 4) or 14 days (n = 4) postoperatively. Spinal tissues were examined after gross dissection and with bright field and fluorescent microscopy.

RESULTS

Needle endoscopy of the cervical canal by ventral approach was associated with intraoperative spinal cord puncture (2/5) and postoperative ataxia (3/5). No intraoperative complications occurred, and one (1/3) horse developed ataxia with cell transplantation under fluoroscopy alone. Umbilical cord-derived MSC were associated with small vessels and detected up to 14 days in the spinal cord. Demyelination was observed in six of eight cases.

CONCLUSION

Fluoroscopically guided intramedullary UC-MSC transplantation during CVIF avoids spinal cord trauma and decreases risk of ataxia from endoscopy. Umbilical cord-derived MSC persist in the spinal cord for up to 14 days. Cell injection promotes angiogenesis and induces demyelination of the spinal tissue.

CLINICAL SIGNIFICANCE

Umbilical cord-derived MSC transplantation into the spinal cord during CVIF without endoscopy is recommended for future evaluation of cell therapy in horses affected by cervical vertebral compressive myelopathy.

Pharmacokinetics of low-dose methotrexate in horses

This study aimed to investigate both the pharmacokinetic behavior and tolerance of methotrexate (MTX) in horses to design a specific dosing regimen as a new immunomodulatory drug for long-term treatment. To determine the primary plasma pharmacokinetic variables after single intravenous, subcutaneous or oral administration, six horses were administered 0.3 mg/kg MTX in a crossover design study. After a 10-week washout, MTX was administered subcutaneously to three of the six previously treated horses at a dose of 0.3 mg/kg once per week for 3 months. In both studies, MTX and metabolite concentrations were measured using LC-MS/MS. The absolute bioavailability of MTX was 73% following subcutaneous administration but less than 1% following oral administration. The plasma clearance was 1.54 ml min^-1  kg^-1 (extraction ratio = 2%). After 24 hr, plasma concentrations were below the LOQ. No adverse effects were noted except for a moderate reversible elevation in liver enzymes (GLDH). With regards to the main metabolites of MTX, very low concentrations of 7-hydroxy-MTX were found, whereas polyglutamated forms (mainly short chains) were found in red blood cells. A subcutaneous dose of 0.2 mg kg^-1  week^-1 may be safe and relevant in horses, although this has yet to be clinically confirmed.

Infected Rastelli Conduit in an Immunocompromised Patient That Was Not Visible on Transthoracic Echocardiogram

An 18-year-old man with a history of right ventricle to pulmonary artery conduit implantation for repair of congenital heart disease and vasculitis requiring chronic immunosuppression with azathioprine presented to the University of Ottawa with bacteremia. A transthoracic echocardiogram revealed no abnormalities at the site of the conduit. A fludeoxyglucose positron emission tomography scan was subsequently obtained that demonstrated an infected right ventricle to pulmonary artery conduit. It is important to remember that, as is true for classic valve endocarditis, an unremarkable transthoracic echocardiogram does not rule out an infected conduit in this population, and nuclear imaging may have important diagnostic utility.

Programme PLUSRx : Pharmacothérapie liée à l’utilisation sécuritaire des médicaments

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Commentary: Opioid use disorder and suicide: An important opportunity to address two significant public health epidemics

Nationwide, the opioid epidemic continues to have a significant and widespread adverse impact on morbidity and mortality. The number of individuals dying by suicide and unintentional overdose has continued to increase over the past decade, with opioids being involved in a significant proportion of each category of mortality in 2017. Currently, most strategies for decreasing opioid-overdose deaths do not include systematic screening for suicide risk, nor do they address the necessity to customize interventions for those who misuse opioids to decrease near-term suicide risk (defined here as less than 72 h) factors. Improved screening of near-term and chronic suicide risk along with rapid access to treatment is of critical importance to prevent opioid-related deaths by suicide.

Identification of discrepancies between adverse drug reactions coded by medical records technicians and those reported by the pharmacovigilance team in pediatrics: An intervention to improve identification, reporting, and coding

OBJECTIVE

To identify the discrepancies between the adverse drug reactions (ADRs) identified by medical records technicians and the ADRs identified by the pharmacovigilance team, and to validate the quality of the information collected by the medical records technicians. To propose improvements to the method for detection of serious ADRs by medical records technicians and the pharmacovigilance team to meet the new requirements of Canada's amended Food and Drug Act (Vanessa's Law) and its regulations.

METHODS

This was a descriptive and retrospective study. We included all ADRs identified by medical records technicians in the coding of records after hospitalization, including active ADRs present at admission or identified during hospitalization between 1 April 2017 and 31 October 2017, and all ADRs identified and reported by the pharmacy through its pharmacovigilance program during the same period. We identified the discrepancies between the two identification systems and revised all cases from patient records. In addition, we identified improvements in the method for detecting and reporting serious ADRs.

RESULTS

This study identified 343 ADRs, 322 of which were coded by the medical records technicians and 21 identified by the pharmacovigilance team for a period of 7 months in a mother-child university hospital center. Only 1.5% of the ADRs were identified by both medical records technicians and the pharmacovigilance team. The code Y43, which corresponds to the largest number of identified ADRs, mainly includes anticancer drugs and immunosuppressant drugs. Three corrective actions were set up: 1) implementation of a form to explain the addition and coding of an ADR to a patient's file, 2) weekly transmission of a working file between the medical records technicians and the pharmacovigilance team so that the files would be reviewed and a declaration made to the regulatory authority, and 3) creation of a standardized pharmacist's note to add to the patient file.

CONCLUSION

It is possible to increase the reporting of ADRs, improve the quality of coding, and reduce discrepancies between the ADRs coded by these two teams through a structured intervention.

Building a CTU Orientation Handbook iPad® application for first-year residents

BACKGROUND

The General Internal Medicine Clinical Teaching Unit (CTU) is a challenging rotation for new residents and the optimal format of orientation has not been determined. We hypothesized that an iPad^® application (app) would be a useful reference tool after residents completed their traditional large group orientation.

METHODS

Postgraduate year 1 (PGY1) residents were sent a link to download the free app one week before the start of their rotation. A pre-usage survey at initial login collected basic demographics. Usage data was collected to determine the sections, duration, and the timeframe from which the app was utilized.

RESULTS

Pre-usage survey data revealed that 63% of participants were female, 69% felt the app would improve orientation, and 94% were comfortable using mobile technology for medical education. Usage data showed "Teaching Sessions and Schedules," "The Consult Note," and "Admission Orders" were the three sections most commonly used. The most usage was during the evening call shift (10pm to 6am), followed by the morning shift (6am to 5pm).

CONCLUSION

The CTU Orientation App was a useful supplement to the traditional orientation. Researchers may not be able to predict what content would be most valuable in an iPad^® app, thus pre-development needs-assessments and usage feedback are crucial.

The implementation and evaluation of an e-Learning training module for objective structured clinical examination raters in Canada

Improving the reliability and consistency of objective structured clinical examination (OSCE) raters' marking poses a continual challenge in medical education. The purpose of this study was to evaluate an e-Learning training module for OSCE raters who participated in the assessment of third-year medical students at the University of Ottawa, Canada. The effects of online training and those of traditional in-person (face-to-face) orientation were compared. Of the 90 physicians recruited as raters for this OSCE, 60 consented to participate (67.7%) in the study in March 2017. Of the 60 participants, 55 rated students during the OSCE, while the remaining 5 were back-up raters. The number of raters in the online training group was 41, while that in the traditional in-person training group was 19. Of those with prior OSCE experience (n= 18) who participated in the online group, 13 (68%) reported that they preferred this format to the in-person orientation. The total average time needed to complete the online module was 15 minutes. Furthermore, 89% of the participants felt the module provided clarity in the rater training process. There was no significant difference in the number of missing ratings based on the type of orientation that raters received. Our study indicates that online OSCE rater training is comparable to traditional face-to-face orientation.

How do formative objective structured clinical examinations drive learning? Analysis of residents' perceptions

INTRODUCTION

Although several studies have explored the relationship between learning and written tests, little is understood about how performance-based examinations influence learning. The purpose of this study was to explore how a formative objective structured clinical examination (OSCE) drives learning.

METHODS

We administered surveys to residents (n = 35) at three time points to determine if and how an OSCE influenced their learning: before and immediately following the OSCE, and after the distribution of their results. Differences in quantitative responses between high- and low-performing residents and across time were compared using repeated-measures ANOVA. Thematic analysis was used to analyze narrative comments.

RESULTS

Participants' goals for the OSCE related to performance, mastery and feedback. Almost all participants reported that they had learned something from the OSCE (94%) and most participants generated learning goals after the OSCE (71%). High performers appeared to recognize the importance of content-related knowledge for scoring well before and after the OSCE, whereas low performers may have under-estimated its importance until after the examination.

DISCUSSION

Participants viewed a formative OSCE as both a hurdle to overcome (assessment of learning) and an opportunity to learn (assessment for learning). Understanding how OSCEs influence study behavior can help guide the development of assessments that promote learning.

Seroprevalence of horses to Coxiella burnetii in an Q fever endemic area

Coxiella burnetii can infect many animal species, but its circulation dynamics in and through horses is still unclear. This study evaluated horse exposure in an area known to be endemic for ruminants and humans. We assessed antibody prevalence in horse serum by ELISA, and screened by qPCR horse blood, ticks found on horses and dust from stables. Horse seroprevalence was 4% (n = 335, 37 stables) in 2015 and 12% (n = 294, 39 stables) in 2016. Of 199 horses sampled both years, 13 seroconverted, eight remained seropositive, and one seroreverted. Seropositive horses were located close to reported human cases, yet none displayed Q fever-compatible syndromes. Coxiella DNA was detected in almost 40% of collected ticks (n = 59/148 in 2015; n = 103/305 in 2016), occasionally in dust (n = 3/46 in 2015; n = 1/14 in 2016) but never in horse blood. Further studies should be implemented to evaluate if horses may be relevant indicators of zoonotic risk in urban and suburban endemic areas.

One particular Anaplasma phagocytophilum ecotype infects cattle in the Camargue, France

Background

Anaplasma phagocytophilum is a zoonotic tick-borne pathogen responsible for granulocytic anaplasmosis, a mild to a severe febrile disease that affects man and several animal species, including cows and horses. In Europe, I. ricinus is the only proven vector for this pathogen, but studies suggest that other tick genera and species could be involved in its transmission. Our objective was to assess the presence and genetic diversity of A. phagocytophilum in domestic animals and different tick species from the Camargue region, located in the south of France.

Methods

A total of 140 ticks and blood samples from 998 cattle and 337 horses were collected in Camargue and tested for the presence of A. phagocytophilum DNA by msp2 quantitative real-time PCR. Molecular typing with four markers was performed on positive samples.

Results

Anaplasma phagocytophilum DNA was detected in 6/993 (0.6%) cows, 1/20 (5%) Haemaphysalis punctata, 1/57 (1.75%) Rhipicephalus pusillus, and was absent in horses (0%). All cattle A. phagocytophilum presented a profile identical to an A. phagocytophilum variant previously detected in Dermacentor marginatus, Hyalomma marginatum, and Rhipicephalus spp. in Camargue.

Conclusions

Our results demonstrate that one particular A. phagocytophilum variant infects cattle in Camargue, where I. ricinus is supposed to be rare or even absent. Dermacentor marginatus, Rhipicephalus spp. and Hyalomma spp., and possibly other tick species could be involved in the transmission of this variant in this region.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-017-2305-3) contains supplementary material, which is available to authorized users.

Successful medical treatment of an Aspergillus terreus mycetoma of the nostril/lip in a 16-year-old Fjord pony gelding with pituitary pars intermedia dysfunction

BACKGROUND

Mycetoma is a chronic, proliferative lesion of cutaneous/subcutaneous tissue characterized by draining tracts and granules in the discharge caused by actinomycetes (actinomycetoma) or filamentous fungi (eumycotic mycetoma).

OBJECTIVES

This case report describes the unusual finding of a cutaneous mycetoma of the lateral wing of the right nostril in a gelding.

ANIMAL

A 16-year-old Fjord gelding with suspected pituitary pars intermedia dysfunction (PPID) was presented for evaluation of a nonpainful, firm and raised mass involving the lateral wing of the right nostril and the lip.

METHODS AND RESULTS

Cytological examination of the mass showed marked pyogranulomatous inflammation and histopathological examination revealed a fungal mycetoma. Fungal culture identified the causative organism as Aspergillus terreus, which is not known for its propensity to cause either dermal granulomas or mycetoma in domestic animals. Further investigation, including a TRH stimulation test, led to a diagnosis of PPID (Cushing's disease), which may have led to immunosuppression of the animal and increased susceptibility to infection.

CONCLUSIONS AND CLINICAL IMPORTANCE

The horse was treated medically with pergolide for the PPID and oral potassium iodide for the fungal infection, with good therapeutic response and no relapse after five months. Surgical debridement or excision was not performed. To the best of the authors' knowledge, this is the first case report of a cutaneous mycetoma caused by A. terreus in a horse.

Done or Almost Done? Improving OSCE Checklists to Better Capture Performance in Progress Tests

Construct: The impact of using nonbinary checklists for scoring residents from different levels of training participating in objective structured clinical examination (OSCE) progress tests was explored.

BACKGROUND

OSCE progress tests typically employ similar rating instruments as traditional OSCEs. However, progress tests differ from other assessment modalities because learners from different stages of training participate in the same examination, which can pose challenges when deciding how to assign scores. In an attempt to better capture performance, nonbinary checklists were introduced in two OSCE progress tests. The purposes of this study were (a) to identify differences in the use of checklist options (e.g., done satisfactorily, attempted, or not done) by task type, (b) to analyze the impact of different scoring methods using nonbinary checklists for two OSCE progress tests (nonprocedural and procedural) for Internal Medicine residents, and (c) to determine which scoring method is better suited for a given task.

APPROACH

A retrospective analysis examined differences in scores (n = 119) for two OSCE progress tests (procedural and nonprocedural). Scoring methods (hawk, dove, and hybrid) varied in stringency in how they awarded marks for nonbinary checklist items that were rated as done satisfactorily, attempted, or not done. Difficulty, reliability (internal consistency), item-total correlations and pass rates were compared for each OSCE using the three scoring methods.

RESULTS

Mean OSCE scores were highest using the dove method and lowest using the hawk method. The hawk method resulted in higher item-total correlations for most stations, but there were differences by task type. Overall score reliability calculated using the three methods did not differ significantly. Pass-fail status differed as a function of scoring methods and exam type, with the hawk and hybrid methods resulting in higher failure rates for the nonprocedural OSCE and the dove method resulting in a higher failure rate for the procedural OSCE.

CONCLUSION

The use of different scoring methods for nonbinary OSCE checklists resulted in differences in mean scores and pass-fail status. The results varied with procedural and nonprocedural OSCEs.

Suicide Risk Assessment in Hospitals: An Expert System-Based Triage Tool

BACKGROUND

The November 2010 Joint Commission Sentinel Event Alert on the prevention of suicides in medical/surgical units and the emergency department (ED) mandates screening every patient treated as an outpatient or admitted to the hospital for suicide risk. Our aim was to develop a suicide risk assessment tool to (1) predict the expert psychiatrist's assessment for risk of committing suicide within 72 hours in the hospital, (2) replicate the recommended intervention by the psychiatrist, and (3) demonstrate acceptable levels of participant satisfaction.

METHODS

The 3 phases of tool development took place between October 2012 and February 2014. An expert panel developed key questions for a tablet-based suicide risk questionnaire. We then performed a randomized cross-sectional study comparing the questionnaire to the interview by a psychiatrist, for model derivation. A neural network model was constructed using 255 ED participants. Evaluation was the agreement between the risk/intervention scores using the questionnaire and the risk/intervention scores given by psychiatrists to the same patients. The model was validated using a new population of 124 participants from the ED and 50 participants from medical/surgical units.

RESULTS

The suicide risk assessment tool performed at a remarkably high level. For levels of suicide risk (minimal or low, moderate, or high), areas under the curves were all above 0.938. For levels of intervention (routine, specialized, highly specialized, or secure), areas under the curves were all above 0.914. Participants reported that they liked the tool, and it took less than a minute to use.

CONCLUSIONS

An expert-based neural network model predicted psychiatrists' assessments of risk of suicide in the hospital within 72 hours. It replicated psychiatrist-recommended interventions to mitigate risk in EDs and medical/surgical units.

The impact of cueing on written examinations of clinical decision making: a case study

CONTEXT

Selected-response (SR) formats (e.g. multiple-choice questions) and constructed-response (CR) formats (e.g. short-answer questions) are commonly used to test the knowledge of examinees. Scores on SR formats are typically higher than scores on CR formats. This difference is often attributed to examinees being cued by options within an SR question, but there could be alternative explanations. The purpose of this study was to expand on previous work with regards to the cueing effect of SR formats by directly contrasting conditions that support cueing versus memory of previously seen questions.

METHODS

During an objective structured clinical examination, students (n = 144) completed two consecutive stations in which they were presented with the same written cases but in different formats. Group 1 students were presented with CR questions followed by SR questions. Group 2 students were presented with questions in reverse order. Participants were asked to describe their testing experience.

RESULTS

Selected-response scores (M = 4.21/10) were statistically higher than the CR scores (M = 3.82/10). However, there was no significant interaction between sequence and format (F(1,142) = 1.59, p = 0.21, ηp2 = 0.01) with scores increasing from 3.49/10 to 4.06/10 in the group that started with CR and decreasing (4.38/10-4.15/10) in the group that started with SR first. Correlations between SR scores and CR scores were high (CR first = 0.78, SR first = 0.89). Questionnaire results indicated that students felt the SR format was easier and led to cueing.

CONCLUSION

To better understand test performance, it is important to know how different response formats could influence results. Because SR scores were higher than CR scores, irrespective of the format seen first, the pattern is consistent with what would be expected if cueing rather than memory for prior questions led to higher SR scores. This could have implications for test designers, especially when selecting question formats.

Bioequivalence study of two different tablet formulations of donepezil using truncated areas under the curve. A single-center, single-dose, randomized, open-label, 2-way crossover study under fasting conditions

BACKGROUND

Donepezil hydrochloride (CAS 120014-06-4) is a piperidine-based, reversible inhibitor of the enzyme acetylcholinesterase (AChE). It is postulated to exert its therapeutic effect by enhancing cholinergic function. This is accomplished by increasing the concentration of acetylcholine (ACh) through reversible inhibition of its hydrolysis by AChE.

OBJECTIVE

The aim of this study was to assess the bioequivalence of a new donepezil 10 mg formulation (test formulation) vs. the reference product, as required by European regulatory authorities for the marketing of a generic product. Additionally, the applicability of the truncated area under the plasma concentration curve (AUC) approach to this drug and under these test conditions was determined.

METHODS

This was a single center, randomized, single-dose, open-label, 2-way crossover study in healthy volunteers under fasting conditions. Plasma samples were collected up to 288 h post-dosing and (+)-donepezil and (-)-donepezil plasma levels were determined by reverse liquid chromatography and by tandem mass spectrometry detection (ie, the LCMS/MS method). Pharmacokinetic parameters were calculated using non-compartmental analysis. Area under the concentration-time curve from time zero to the time of the last non-zero concentration (AUC(last)) and maximum observed concentration (C(max)) were the main evaluation criteria, while area under the concentration-time curve from time zero to infinity (AUC(inf)) was also analyzed for additional information. For the assessment of the applicability of the truncated AUC approach, AUCs truncated at 24, 48, 72, 96, 144, 192, 240, and 288 h were calculated. All of the abovementioned pharmacokinetic parameters were analyzed using 90% geometric confidence interval of the ratio (T/R) of least-squares means from the ANOVA of the In-transformed parameter. Tolerability was monitored using physical examination, including vital sign measurements and laboratory analysis.

RESULTS

According to the classical approach, the 90% geometric confidence intervals obtained by analysis of variance for AUC(last), C(max) and AUC(inf) were within the predefined ranges (80.00-125.00%) for both analytes. Truncated AUCs were also in all cases within the predefined ranges for acceptance of bioequivalence.

CONCLUSION

Bioequivalence between test and reference formulations, both in terms of rate and extension of absorption, under fasting conditions, was concluded according to European guidelines. Both formulations were well tolerated. The conclusion of bioequivalence was also supported using the truncated AUCs approach.

Comparison of TGF-beta 1 concentrations in bronchoalveolar fluid of horses affected with heaves and of normal controls

Airway remodeling may play an important role in heaves pathophysiology. Transforming growth factor-beta 1 (TGF-beta1) is a potent profibrotic cytokine, which might contribute to airway wall thickening and fibrosis of bronchiolar and alveolar submucosa. An ELISA designed for the measurement of human TGF-beta1 was used to measured total TGF-beta1 released in bronchoalveolar lavage fluid (BALF) of normal horses and of those affected with heaves in remission. The specificity of the assay for TGF-beta1 of the horse was confirmed using recombinant equine TGF-beta1. The influence of hay exposure on TGF-beta1 release in the airways was also examined by stabling horses in a dusty environment. TGF-beta1 was found in the BALF of all horses. However, no significant difference between basal concentration of TGF-beta1 in BALF of control horses versus that of horses affected with heaves was found. Furthermore, no differences were identified in these populations 1 and 9 days after allergen challenge. In conclusion, these data indicate that TGF-beta1 is released in BALF fluid of horses in biologically active concentrations. Other studies are necessary for a better definition of the role of this cytokine within the lung, as our study does not establish a causal relationship between TGF-beta1 and the pathophysiology of heaves in the horse.

Free and conjugated estrogens and androgens in stallion semen

The steroid content of semen from a total of 11 mature fertile stallions was studied during two breeding seasons and one winter. The levels of free and conjugated substrates (testosterone and androstenedione), and products (estradiol and estrone), of aromatase were measured by radioimmunoassay with a validated method. The results were seasonally and monthly highly variable with characteristic peaks. The concentrations of free and conjugated estrogens were always higher in the gel-free ejaculate than in the gel except in one subfertile stallion used as comparison. Furthermore, the steroid production and the maximal resulting aromatase activity, estimated by the estrogens/androgens ratio, peaked in April-May and June. The breeding season (spring and summer) presents a clear estrogenic profile with estrogens/androgens ratios higher in contrast to the nonbreeding period (autumn and winter). The involvement of estrogens in the regulation of reproduction and equine spermatogenesis is discussed, and estrogens production and thus equine aromatase is proposed as a strong marker of testicular endocrine function.

Multifocal subacute necrotizing encephalomyelopathy in a Simmental calf

Multifocal subacute necrotizing encephalomyelopathy affects Simmental and Simmental-cross cattle. First clinical signs are ataxia and hind limb paresis. The characteristic gross lesion is bilaterally symmetrical, grey, depressed to cavitated foci involving nuclei in the brainstem. The caudal olivary nucleus is consistently involved. The etiology of the syndrome remains unknown.