Mobile Clinical Decision Tools Among Emergency Department Clinicians: Web-Based Survey and Analytic Data for Evaluation of The Ottawa Rules App

BACKGROUND

The Canadian CT Head Rule (CCHR), the Canadian Transient Ischemic Attack (TIA) Score, and the Subarachnoid Hemorrhage (SAH) Rule have all previously demonstrated the potential to significantly standardize care and improve the management of patients in emergency departments (EDs). On the basis of user feedback, we believe that the addition of these rules to the Ottawa Rules App has the potential to increase the app's usability and user acceptability.

OBJECTIVE

This study aimed to evaluate the perceived usefulness, acceptability, and uptake of the enhanced Ottawa Rules App (which now includes CCHR, TIA, and SAH Rules) among ED clinicians (medical students, residents, nurses, and physicians).

METHODS

The enhanced Ottawa Rules App was publicly released for free on iOS and Android operating systems in November 2018. This study was conducted across 2 tertiary EDs in Ottawa, Canada. Posters, direct enrollment, snowball sampling, and emails were used for study recruitment. A 24-question Web-based survey was administered to participants via email, and this was used to determine user acceptability of the app and Technology Readiness Index (TRI) scores. In-app user analytics were collected to track user behavior, such as the number of app sessions, length of app sessions, frequency of rule use, and the date app was first opened.

RESULTS

A total of 77 ED clinicians completed the study, including 34 nurses, 12 residents, 14 physicians, and 17 medical students completing ED rotations. The median TRI score for this group was 3.38, indicating a higher than average propensity to embrace and adopt new technologies to accomplish goals in their work or daily lives. The majority of respondents agreed or strongly agreed that the app helped participants accurately carry out the clinical rules (56/77, 73%) and that they would recommend this app to their colleagues (64/77, 83%). Feedback from study participants suggested further expansion of the app-more clinical decision rules (CDRs) and different versions of the app tailored to the clinician role. Analysis and comparison of Google Analytics data and in-app data revealed similar usage behavior among study-enrolled users and all app users globally.

CONCLUSIONS

This study provides evidence that using the Ottawa Rules App (version 3.0.2) to improve and guide patient care would be feasible and widely accepted. The ability to verify self-reported user data (via a Web-based survey) against server analytics data is a notable strength of this study. Participants' continued app use and request for the addition of more CDRs warrant the further development of this app and call for additional studies to evaluate its feasibility and usability in different settings as well as assessment of clinical impact.

Immunization and technology among newcomers: A needs assessment survey for a vaccine-tracking app

Objectives: Newcomers experience unique challenges with respect to vaccination. These challenges are compounded by the need to navigate complex vaccination catch-up schedules upon arrival in their new home countries. Our group has pioneered the development of CANImmunize, a free, bilingual, pan-Canadian digital application designed to empower individuals to manage their vaccination records. To inform how a vaccine tracking app such as CANImmunize might be tailored to meet the unique needs of newcomers, this study sought to determine commonly spoken languages, technology use, and current methods of vaccine tracking among recent newcomers to Canada.

Methods: Government-assisted refugees attending a health clinic in Ottawa, Canada were invited to complete a 17-question needs assessment survey. The survey captured data on household demographics, spoken languages, country of origin, technology use and methods used to track vaccination history.

Results: 50 newcomers completed the needs assessment survey. Arabic was the predominant language spoken by surveyed individuals. Although 92% of participants owned a smartphone, the majority did not actively use digital health applications. 18 (36%) participants reported being vaccinated before arriving in Canada. 27 (54%) participants were parents, 23 of whom reported that their children were vaccinated prior to arrival in Canada. 38 (76%) participants indicated that they would use a vaccine tracking app such as CANImmunize if it were translated into their primary language of communication.

Conclusions: The results of our study indicate that mobile technology may be a useful tool to help newcomer families stay on track with provincial and territorial immunization schedules.

Acceptability of a Mobile Clinical Decision Tool Among Emergency Department Clinicians: Development and Evaluation of The Ottawa Rules App

Background

The Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule—together known as The Ottawa Rules—are a set of internationally validated clinical decision rules developed to decrease unnecessary diagnostic imaging in the emergency department. In this study, we sought to develop and evaluate the use of a mobile app version of The Ottawa Rules.

Objective

The primary objective of this study was to determine acceptability of The Ottawa Rules app among emergency department clinicians. The secondary objective was to evaluate the effect of publicity efforts on uptake of The Ottawa Rules app.

Methods

The Ottawa Rules app was developed and publicly released for free on iOS and Android operating systems in April 2016. Local and national news and academic media coverage coincided with app release. This study was conducted at a large tertiary trauma care center in Ottawa, Canada. The study was advertised through posters and electronically by email. Emergency department clinicians were approached in person to enroll via in-app consent for a 1-month study during which time they were encouraged to use the app when evaluating patients with suspected knee, foot, or neck injuries. A 23-question survey was administered at the end of the study period via email to determine self-reported frequency, perceived ease of use of the app, and participant Technology Readiness Index scores.

Results

A total of 108 emergency department clinicians completed the study including 42 nurses, 33 residents, 20 attending physicians, and 13 medical students completing emergency department rotations. The median Technology Readiness Index for this group was 3.56, indicating a moderate degree of openness for technological adoption. The majority of survey respondents indicated favorable receptivity to the app including finding it helpful to applying the rules (73/108, 67.6%), that they would recommend the app to colleagues (81/108, 75.0%), and that they would continue using the app (73/108, 67.6%). Feedback from study participants highlighted a desire for access to more clinical decision rules and a higher degree of interactivity of the app. Between April 21, 2016, and June 1, 2017, The Ottawa Rules app was downloaded approximately 4000 times across 89 countries.

Conclusions

We have found The Ottawa Rules app to be an effective means to disseminate the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule among all levels of emergency department clinicians. We have been successful in monitoring uptake and access of the rules in the app as a result of our publicity efforts. Mobile technology can be leveraged to improve the accessibility of clinical decision tools to health professionals.

Expression of E- and P-selectin in Tumor Necrosis Factor—induced Dermatitis in Dogs

Adhesion molecules on endothelial cells play an important role in leukocyte recruitment in several inflammatory processes. Vascular selectins mediate the initial adhesion of leukocytes to the blood vessel wall during their extravasation into inflamed tissues, and in vitro studies in dogs have shown that selectin expression can be induced by cytokines such as tumor necrosis factor-α (TNF-α) and interleukin-1 (IL-1). The objective of this study was to determine whether vascular selectins are induced by cytokines in vivo in a cutaneous model of inflammation in dogs. Skin biopsies were collected from nine dogs at various time points after an intradermal injection of TNF-α (10 ng/site) or phosphate-buffered saline containing 0.1% bovine serum albumin, and immunohistochemistry was performed using anti-P-selectin (MD3) and anti-E-selectin (CL37) monoclonal antibodies. In all animals, TNF-α induced an inflammatory reaction that was maximal at 12 hours and then decreased by 24 and 48 hours. Control skin displayed no expression of E- and P-selectin, whereas TNF-α induced the expression of P-selectin and E-selectin on dermal vessels that was highest at 12 hours and 3 hours, respectively ( P < 0.05). Numerous platelet aggregates recognized by the anti-P-selectin antibody were present in the lumina of vessels and in perivascular tissues. These results demonstrate that TNF-α can induce the expression of P- and E-selectin in vivo in dog skin and suggest that these selectins are involved in leukocyte recruitment in canine dermatitis.

[Miliary cerebral carcinomatosis secondary to EGFR mutation-positive lung adenocarcinoma]

INTRODUCTION

Miliary brain metastases are a rare form of brain metastatic lesions.

CASE REPORT

We report the case of a 58-year-old patient with lung adenocarcinoma and an EGFR mutation, who had metastatic lesions in the bones, pleura and pericardia at the time of diagnosis. The patient was treated with tyrosine kinase inhibitor. A few months later, he presented with progressive neuropsychiatric symptoms, which were attributed to miliary brain metastases based on the radiological pattern (micronodules, some of which were calcified) and the elimination of alternative possible diagnoses. Despite tumour stability in the thorax and metastatic sites other than the brain, his neurological condition deteriorated, even after cerebral radiotherapy, leading to his death eight months after the diagnosis of lung cancer.

CONCLUSION

Miliary brain metastases are a rare form of brain metastases with unusual clinical presentation. The diagnosis is based on the radiological pattern of cerebral miliary dissemination, with sometimes calcified tumor nodules. Despite its rarity, several cases have been reported in lung adenocarcinoma in the presence of EGFR mutations.

Endemic human blastomycosis in Quebec, Canada, 1988-2011

Blastomycosis is a systemic fungal infection found in various parts of the world. A review of literature for Quebec, Canada revealed only few case reports with the most recent one dating back to 1993. However, whether Quebec represents an important endemic region for blastomycosis in North America is unknown. In this work we reviewed 158 cases of human blastomycosis documented in Quebec during 1988-2011 using microbiological records available from the provincial public health laboratory. The estimated annual incidence of blastomycosis in the province is was ~0·133 cases per 100 000 individuals with the highest rates of 0·79 and 0·46 cases per 100 000 recorded in South-eastern and South-western Quebec. Moreover, the annual incidence rate significantly increased over the past 20 years. This study for the first time establishes Quebec as an important endemic region for Blastomyces dermatitidis.

[Infants and toddlers behavioral and functional disorders: characteristics, mother-child interactions, alliance and outcome after a brief parents-child psychotherapy. A pilot study]

OBJECTIVES

Functional and behavioral disorders are the most frequent reasons for consultation in infant psychiatry, but there are still few studies about the efficacy of parents-child psychotherapies. Functional disorders appear to be easier to treat than behavioral disorders. The aim of this study was: (1) to assess outcome after a brief psychotherapy in a population of 49 infants aged 3 to 30 months, presenting functional or behavioral disorders; (2) to compare characteristics before therapy and outcomes for children with functional disorders and with behavioral disorders, to have a better understanding of the worse outcome of children with behavioral disorders.

METHODS

Two assessments were performed, one before treatment and the second a month after the end of the therapy including the infant's symptoms (Symptom Check-list), parents' anxious and depressive symptoms (Hospital Anxiety and Depression scale) and mother-infant interactions (Crittenden Experimental Index of adult-infant relationship). The therapeutic alliance was assessed by the therapist and the parents after the first consultation (Working Alliance Inventory).

RESULTS

The assessments after therapy show complete or partial improvement in the child's symptoms, in the mother's anxious and depressive symptoms and in the father's anxious symptoms. During interaction, the mothers become more sensible, the number of controlling and of unresponsive mothers decrease, while the children become more cooperative and less passive. Initial characteristics and outcome are however different according to the type of the child's disorder. The children with behavioral disorders are older and present an association of several symptoms. The disorder onset is later. Their mothers are, before therapy, more anxious and depressive. The therapeutic alliance is weaker. After therapy, despite the fact that their mothers' affective state and that interactive behavior improves, the mothers are more anxious and less sensible, while the children no longer differ from the group without behavioral disorder from the point of view of opposition (assessed during mother-child interaction).

CONCLUSION

Although this study is limited by the lack of a control group and the sample size, it underlines some particularities of infants and toddlers presenting behavioral disorders and the difficulties involved in their treatment. One can wonder if these characteristics are specific of the behavioral disorders or if they are the result of an older dysfunction, complicated by the developmental evolution of the child and the duration of the difficulties. The small number of cases, among the children with behavioral disorders, presenting a preexistent functional disorder, the absence of difference in the duration of the disorders, and the different disorder's onset plead in favor of the first hypothesis. The behavioral disorders often associate child psychopathology, dysfunctional parents-child-relationships and environmental factors difficult to modify with a brief therapy focused on the relationship. It would appear necessary to develop specific treatments for this population.

[Psychosocial distress and communication about cancer in ill partners and their spouses]

INTRODUCTION

Each cancer can have a psychological impact not only on the patient himself/herself, but also on his/her spouse.

OBJECTIVE

Our study concerned 30 couples encompassing a member treated for a cancer, non related to gender. It was aimed at determining the links between the levels of psychosocial distress measured in both members of each couple, patients' sociodemographic and clinical characteristics, as well as communication skills about cancer in both members of the couples.

METHODS

Psychosocial distress and communication about cancer were measured by the general health questionnaire (GHQ-28) and the openness to discuss cancer in the nuclear family (ODCF), with an additional version adapted for the spouse on the occasion of this study.

RESULTS

A positive correlation was found between the respective scores of the two members of the couples, for the GHQ-28 (r=0.53; p=0.005) as well as for the ODCF (r=0.44; p=0.024). GHQ-28 scores were not associated with the sociodemographic characteristics of the patients, nor with the stage of cancer, the number of months elapsed since the diagnosis of cancer, or the ODCF personal or spouse's score. On the other hand, when the communication within each couple was classified into concordant (insufficient or, on the contrary, open for both members) or discordant (insufficient for one of the two members and open for the other), and after controlling for gender, higher levels of psychosocial distress were found in patients (p=0.038) as well in spouses (p=0.052) belonging to discordant compared with concordant couples.

CONCLUSION

These results suggest an effect of contamination or a mutual reinforcement of the distress of each member of such couples, as well as the presence of relatively similar styles of communication in the two partners of each couple. They also underline the possible adaptive function of a restricted style of communication about cancer, if such a restriction is shared by both the members of the couple, and incites particular attention to be paid to couples where one of the partners, but not the other, adopt an open style of communication about cancer.

Effect of substrate selection on indirect immunofluorescence testing of canine autoimmune subepidermal blistering diseases

The detection by indirect immunofluorescence (IIF) of circulating antibodies in the serum of dogs with autoimmune subepidermal blistering diseases (AISBD) was regarded for a long time as an unrewarding tool. It was, however, demonstrated in humans that the sensitivity of IIF assays depended on the selection of the substrates used. The effects of substrate selection on IIF tests was thus studied by examining sera from 12 dogs with AISBD tested against 8 different substrates from 3 different normal dogs. Patients with AISBD suffered from bullous pemphigoid (n = 4 sera), mucous membrane pemphigoid (n = 4 sera), and epidermolysis bullosa acquisita (n = 4 sera). Substrates included canine tongue, canine lip, canine dorsal haired skin, and ventral haired skin. The same 4 substrates were also split with salt splitting technique (using 1 M sodium chloride), in order to cleave the basement membrane within the lamina lucida and to expose the targeted antigens. The strength of the specific fluorescence of each slide was scored after processing for IIF testing with anti-canine IgG polyclonal antibody. Other criteria, such as background fluorescence, easiness of the interpretation, and variations within a same substrate, were also assessed. Intact canine lip and canine salt-split lip demonstrated consistently stronger intensity of fluorescence and a better ease of interpretation. We concluded that the performance of IIF tests with such substrates was a reliable tool for the detection of circulating IgG autoantibodies of canine patients with AISBD.

Expression of Neisseria gonorrhoeae cell division genes ftsZ, ftsE and minD is influenced by environmental conditions

The activity of the promoter regions of the cell division genes ftsZ, ftsE, minC, minD and minE from Neisseria gonorrhoeae (Ng) was studied under different environmental conditions using lacZ translational fusions. The promoters of the minNg genes have not been previously determined and we identified promoter regions upstream of each gene (minCp, minDp and minEp). We determined that minDp had the strongest activity. Expression of the promoter regions of ftSZ(Ng) and ftsE(Ng), which we had previously identified, as well as minD(Ng), were then studied under conditions reflecting the environment of the genitourinary tract. These conditions included anaerobiosis, presence of isoleucine or urea (3 mM and 400 mM, respectively) and acidity of pH 6. Both beta-galactosidase expression and northern blot analysis indicated that all three genes were upregulated under anaerobiosis. The addition of isoleucine as well as media at pH 6 did not have any significant effects on the promoter activity of these genes while the presence of urea significantly decreased ftsZ(Ng) promoter activity. The expression of the minD(Ng) promoter region was analyzed during different growth phases and shown to follow the growth behavior of the culture. By contrast, the ftSZ(Ng) promoter activity continued to rise after the onset of the stationary phase. When gonococcal ftsZ promoter 1, (Pz1) was altered by site-directed mutagenesis, a significant decrease in the expression of ftsZ(Ng) was observed under both aerobic and anaerobic conditions. These data infer that gonococci regulate their cell division in response to different environments.

Evaluation of the clinical efficacy of marbofloxacin (Zeniquin) tablets for the treatment of canine pyoderma: an open clinical trial

The efficacy and field safety of marbofloxacin (Zeniquin) for the treatment of superficial and deep bacterial pyoderma were evaluated. Seventy-two dogs were treated with 2.75 mg kg-1 of marbofloxacin orally once daily for 21 or 28 days. Sixty-two dogs (86%) had superficial pyoderma and 10 (14%) had deep pyoderma. A history of prior pyoderma was reported in 39/72 dogs. Pretreatment aerobic bacteriologic cultures of skin lesions were performed in 47 cases and the predominant pathogen isolated was Staphylococcus intermedius. Treatment was successful in 62/72 (86.1%) dogs, improvement was noted in 6/72 (8.3%) dogs and treatment failed in 4/72 (5.6%) dogs. Adverse effects associated with treatment included listlessness, anorexia, vomiting, soft stool, flatulence and polydipsia; these adverse effects were seen in only 6/81 dogs. Marbofloxacin was safe and effective for the treatment of superficial and deep pyoderma in dogs at the dosage used in this study.

Dermatophilus-like infection in beluga whales, Delphinapterus leucas, from the St. Lawrence estuary

Six beluga whales (Delphinapterus leucas) found dead on the shores of the St. Lawrence estuary had multiple slightly depressed greyish round areas randomly distributed over the whole body. Histologically, the surface of these areas was covered with a thick layer of Dermatophilus-like organisms which invaded the stratum corneum. The underlying stratum spinosum had marked spongiosis and vacuolar degeneration. Minimal neutrophilic infiltration was present within the underlying dermal papillae. To the authors' knowledge, dermatophilosis in cetaceans has not been reported previously.

Observations on topical ivermectin in the treatment of otoacariosis, cheyletiellosis, and toxocariosis in cats

The purpose of this study was to observe the efficacy of a topical pour-on formulation of ivermectin in the treatment of otoacariosis, cheyletiellosis, and toxocariosis in cats. Forty-five cats were treated. All cats received 2 to 4 topical applications of ivermectin on the skin between the shoulder blades in a narrow strip, 14 days apart. This practical treatment was effective in 96% (23/24) of cases of feline otoacariosis and in 100% (20/20) of cats with toxocariosis. All cats with cheyletiellosis (16/16) received 4 treatments and had resolution of clinical signs, but one Cheyletiella egg could still be found 45 days after the last treatment. The viability of this egg could not be evaluated, but the cats were still free of clinical signs on follow-up 6 months later. The treatment was well tolerated in all the animals. A few cats developed a transient small alopecic area and mild scaling at the site of application of the drug.

Evaluation of thyroid function in dogs suffering from recurrent flank alopecia

Thyroid function was assessed in euthyroid dogs (n = 20), dogs suffering from canine recurrent flank alopecia (CRFA, n = 18), and hypothyroid dogs (n = 21). Blood samples obtained from all dogs in each group were assayed for total thyroxine (TT4), thyrotropin (TSH), and thyroglobulin autoantibody (TgAA) serum concentrations. Total T4 and TSH serum concentrations were significantly decreased and increased, respectively, in the hypothyroid group compared with the other 2 groups. No significant differences in TT4 and TSH serum values were found between the euthyroid and CRFA groups. Thyroglobulin autoantibodies were detected in 10, 11.1, and 61.9% of euthyroid dogs, dogs with CRFA, and hypothyroid dogs, respectively. In conclusion, dogs suffering from CRFA have a normal thyroid function, and the determination of TT4 and TSH serum concentrations allows differentiation of these dogs from dogs with hypothyroidism, in most cases. Occasionally, the 2 diseases can be concomitant.

Use of recombinant human thyroid-stimulating hormone for thyrotropin stimulation test in euthyroid dogs

The purpose of this study was to evaluate the effects of the recombinant human thyroid-stimulating hormone (rhTSH) on serum total thyroxine (TT4) concentration in euthyroid dogs. Six healthy beagle dogs were used in each of the 3 phases of this study. Phase I: thyroid-stimulating hormone response tests were performed by using a total dose of 25 micrograms, 50 micrograms, and 100 micrograms of rhTSH, administered intravenously. Phases II and III: thyroid-stimulating hormone response tests were performed by using 50 micrograms of rhTSH administered by intramuscular and subcutaneous routes, respectively. In each phase and following all the administered doses of rhTSH, an increase in the serum TT4 concentration was noted, although it was not always significant. For phase I, there was a significant increase in serum TT4 concentrations. Based on this study, 50 micrograms was judged to be the optimal intravenous dose of rhTSH. For phases II and III, there was no significant increase in serum TT4 after the administration of rhTSH. Results of this study suggest that rhTSH could be a good substitute for bovine TSH, when used by the intravenous route, for the TSH stimulation test in dogs. Further studies are required to confirm its clinical usefulness.

Generalizable outcomes of bilingual aphasia research

A number of constructs developed to account for bilingual aphasia phenomena have been advantageously extended to increase our understanding of language representation, processing, breakdown and rehabilitation in unilinguals as well. In particular, focus on the right-hemisphere-based pragmatic component of verbal communicative competence, the activation threshold, the control of resources, the role of emotion in second language acquisition and that of procedural vs. declarative memory, has led to the suggestion that unilinguals are in fact at one end of a continuum, with multilinguals who speak genetically unrelated languages at the other end. No function is available to the bilingual speaker that is not already available to the unilingual, unidialectal speaker. The only difference seems to be the degree of use the speaker makes of each of the relevant cerebral systems.

New approaches to the treatment of canine demodicosis

Topical amitraz is the only approved treatment for CGD; however, it is not always effective or well tolerated. Extra-label use of amitraz, milbemycin oxime, ivermectin, and moxidectin may be effective therapeutical alternatives for dogs with resistant CGD or dogs that have an intolerance to the licensed amitraz protocol. It appears that oral administration of milbemycin oxime (1-2 mg/kg), ivermectin (400-600 micrograms/kg), and moxidectin (400 micrograms/kg) daily is a practical therapeutical alternative and would provide similar cure rates. Nevertheless, milbemycin oxime is expensive, ivermectin is potentially more toxic, and only limited information is available on moxidectin. The average treatment duration with these new regimens is 4 months, with an expected range of 3 to 10 months. Treatment should be administered daily for a minimum of 3 months and for at least 1 month after a series of negative skin scrapings. For chronic cases or cases that take a relatively long time to respond to therapy, 2 to 3 months of treatment beyond negative scrapings may be more appropriate. Dogs with CGD always approach clinical normalcy weeks to months before negative skin scrapings are obtained. All dogs respond at their own rate; as long as the skin scrapings at each visit show fewer mites, the current therapy should be continued for an additional month. If the mite count starts to increase, this may suggest that the treatment protocol is not being followed or it may be that the therapy chosen was suboptimally effective. Although CGD is still a disease that is not easily treated, the prognosis for dogs with this disorder has dramatically improved in the past few years. It must be remembered, however, that the treatment alternatives for CGD described above are not approved and should not be used unless the approved therapeutical regimen has failed.

Short-term influence of prednisone and phenobarbital on thyroid function in euthyroid dogs

The short-term effects of prednisone and phenobarbital on serum total thyroxine (tT4), free thyroxine (fT4), and thyroid stimulating hormone (TSH) were evaluated in euthyroid dogs. Twenty-six beagles were randomly divided into 3 groups receiving, respectively, a placebo, prednisone (1.2 to 2 mg/kg body weight, per os, every 12 hours for 3 weeks), or phenobarbital (1.8 to 3 mg/kg body weight for 1 week, then 2.7 to 4.5 mg/kg body weight, per os, every 12 hours for 2 weeks). Blood samples taken over a 6-week period were assayed for serum tT4, fT4, and TSH. Phenobarbital therapy in our study did not affect serum tT4, fT4, or TSH concentrations. Prednisone therapy, however, significantly decreased serum tT4 and fT4, but did not affect serum TSH concentrations.

[Reflection on the project PSI-La Boussole]

The "Psi-La Boussole" project constitutes a model of coordination of services characterized by two currents: case management and coordination of Individualized Service Plan (ISP). Its objectives consists in improving autonomy, social integration and quality of life of persons with severe mental disorders, as well as reducing the burden of families and favor a partnership between different resources. From Spring 1992 to January 1996, in Quebec City, 28 people with mental disorder participated in the project. After presenting their profiles, a synthesis of the analysis of 8 history cases allows to put in light the particularities of the model and its functioning.

Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer

BACKGROUND

Radiotherapy after mastectomy to treat early breast cancer has been known since the 1940s to reduce rates of local relapse. However, the routine use of postoperative radiotherapy began to decline in the 1980s because it failed to improve overall survival. We prospectively tested the efficacy of combining radiotherapy with chemotherapy.

METHODS

From 1978 through 1986, 318 premenopausal women with node-positive breast cancer were randomly assigned, after modified radical mastectomy, to receive chemotherapy plus radiotherapy or chemotherapy alone. Radiotherapy was given to the chest wall and locoregional lymph nodes between the fourth and fifth cycles of cyclophosphamide, methotrexate, and fluorouracil.

RESULTS

After 15 years of follow-up, the women assigned to chemotherapy plus radiotherapy had a 33 percent reduction in the rate of recurrence (relative risk, 0.67; 95 percent confidence interval, 0.50 to 0.90) and a 29 percent reduction in mortality from breast cancer (relative risk, 0.71; 95 percent confidence interval, 0.51 to 0.99), as compared with the women treated with chemotherapy alone.

CONCLUSIONS

Radiotherapy combined with chemotherapy after modified radical mastectomy decreases rates of locoregional and systemic relapse and reduces mortality from breast cancer.

Topical (pour-on) ivermectin in the treatment of canine scabies

The efficacy of a pour-on formulation of ivermectin at 500 micrograms/kg body weight applied on the dorsum on days 1 and 15 was evaluated in 90 dogs from a shelter, naturally infested with Sarcoptes scabiei. This very practical form of treatment was successful in eradicating scabies from this shelter.

Serum free thyroxine concentrations measured by chemiluminescence in hyperthyroid and euthyroid cats

Serum free thyroxine (FT4) concentrations using chemiluminescence were measured in hyperthyroid cats (n = 72) and clinically normal cats (n = 129) to establish reference values and to determine if this method could be a useful alternative to total T4 (TT4) measurement by radioimmunoassay (RIA). Mean serum FT4 concentration (68.3 +/- 26.8 pmol/L) of hyperthyroid cats was significantly higher than that of euthyroid cats (22.9 +/- 4.8 pmol/L). Reference values for basal FT4 of hyperthyroid and healthy cats were 33 to 114 pmol/L and 16 to 30 pmol/L, respectively. The results of the present study suggest that FT4 measured by chemiluminescence could be a useful alternative to TT4 measured by RIA when evaluating thyroid function in cats, since the hazardous effects of radioactive materials on the manipulators and the environment could be avoided. Further studies are required to corroborate these preliminary findings.

Serum-free thyroxine concentrations, measured by chemiluminescence assay before and after thyrotropin administration in healthy dogs, hypothyroid dogs, and euthyroid dogs with dermathopathies

The purpose of this study was to determine the usefulness of free thyroxine (FT4) measured by chemiluminescence in evaluating thyroid function in dogs. Total thyroxine (TT4) concentration measured by radioimmunoassay (RIA) and FT4 measured by chemiluminescence were evaluated in 30 healthy dogs, 60 euthyroid dogs with concurrent dermatopathies, and 30 hypothyroid dogs before and after intravenous stimulation with 1 or 2 IU of thyrotropin (TSH). Median basal TT4 and median TT4 concentrations at 4 h post-TSH administration were not significantly different (P < 0.0001) between healthy dogs and euthyroid dogs with dermatopathies, but were significantly higher than those in hypothyroid dogs. In healthy dogs, the median TT4 concentrations at 4 and 6 h post-TSH administration were not significantly different. Median basal FT4 and median FT4 concentrations at 4 h post-TSH administration in healthy dogs were significantly lower (P < 0.0001) than those in euthyroid dogs with dermatopathies, but significantly higher than the same parameters in hypothyroid dogs. There was a significant difference between the median FT4 concentrations at 4 h post-TSH administration and median basal FT4 concentrations for healthy dogs and euthyroid dogs with dermatopathies, but not for hypothyroid dogs. Lastly, in healthy dogs, median FT4 concentrations at 4 and 6 h post-TSH administration were not significantly different. Free thyroxine measured by chemiluminescence was highly correlated (P < 0.0001; Spearman r = 0.91) with FT4 measured by the reference method for free hormone analysis, namely, equilibrium dialysis, when sera from 56 dogs were used.

Effect of CI-988 on cholecystokinin tetrapeptide-induced panic symptoms in healthy volunteers

A randomized, placebo-controlled, double-blind, three-way crossover design was used to evaluate the effectiveness of single oral 100 mg doses of CI-988, a cholecystokinin B (CCKB) antagonist, in attenuating panic symptoms induced by intravenous injection of cholecystokinin-tetrapeptide (CCK-4). Thirty healthy men received the following treatments on three separate occasions: placebo capsules/placebo, placebo capsules/CCK-4, or CI-988 capsules/CCK-4. There was no marked difference in the number, time to onset, or duration of panic symptoms between CI-988/CCK-4 and placebo/CCK-4. There was, however, a 14% difference in sum intensity scores between these treatments that was statistically significant (p = 0.039). The symptoms most affected by CI-988 were cold chills/hot flushes, chest pain/discomfort, and anxiety/fear/apprehension. Panic attack frequency also decreased following CI-988 treatment (8/30 vs. 16/30; p = 0.035). This decrease, amid otherwise modest effects, could be explained by a preferential effect of CI-988 on the subjective experience of anxiety/fear/apprehension. Possible reasons for the relatively modest effects of CI-988 on CCK-4-induced panic symptoms are discussed.

Ivermectin for treatment of generalized demodicosis in dogs

OBJECTIVE

To evaluate the efficacy of daily administration of ivermectin in the treatment of dogs with amitraz-resistant generalized demodicosis.

DESIGN

Prospective, clinical trial.

ANIMALS

Twelve privately owned dogs with juvenile-onset or adult-onset generalized demodicosis that had failed to respond to biweekly or weekly applications of 0.025% amitraz solution.

PROCEDURE

All dogs were treated with undiluted ivermectin at a dosage of 0.6 mg/kg of body weight, PO, every 24 hours. There was no other parasiticidal agent given topically or systemically. A physical examination and multiple skin scrapings were performed every 2 to 4 weeks while dogs were receiving ivermectin. Skin scrapings were performed at approximately the same sites at every examination. After no mites were seen, treatment was continued for at least 2 more weeks and then stopped. Dogs were reexamined, and skin scrapings were repeated if any skin lesions developed. For dogs that remained clinically normal, follow-up information was obtained by telephone. Dogs that were free of clinical signs of demodicosis 12 months after ivermectin administration was discontinued were considered cured.

RESULTS

Ten of 12 dogs were cured. Median duration of treatment for these dogs was 10 weeks (range, 6 weeks to 5 months). Two dogs were failures, relapsing 10 months and 11.5 months after treatment was stopped. One of these dogs was successfully treated with a second course of ivermectin. Mild ivermectin toxicosis developed in 1 dog after 6 weeks of treatment; side effects resolved shortly after the treatment was stopped.

CLINICAL IMPLICATIONS

Daily use of ivermectin, at a dosage of 0.6 mg/kg, PO, was found to be effective in the treatment of generalized demodicosis in dogs.

Another sighting of differential language laterality in multilinguals, this time in Loch Tok Pisin: comments on Wuillemin, Richardson, and Lynch (1994)

Wuillemin, Richardson, and Lynch (1994) claim to have determined that languages learned after the age of 8 are less lateralized than those learned earlier. The authors fail to specify the nature of what it is that is differentially lateralized. It cannot be implicit linguistic competence (the language system), since that has been clinically demonstrated to be false. It cannot be pragmatic and paralinguistic aspects of language use, since, to the extent that these are right-hemisphere based functions, they could not be reflected in results obtained with a technique assumed to selectively tap left-hemisphere functions. Either way, the visual half-field technique used proves to be an invalid measure of language laterality in individuals or subgroups.

Effects of administration of a low dose of frozen thyrotropin on serum total thyroxine concentrations in clinically normal dogs

Thyroid function was evaluated in 18 healthy dogs by thyrotropin (TSH) stimulation. Two dose regimens were used in each dog: 0.1 IU/kg body weight of freshly reconstituted lyophilized TSH and 1 IU/dog of previously frozen and stored TSH (up to 200 days), both given intravenously. Blood samples were collected prior to and at four and six hours after TSH administration. Serum was evaluated for total thyroxine concentrations by radioimmunoassay. All dogs were classified as euthyroid on the basis of response to 0.1 IU/kg body weight of freshly reconstituted TSH at four and six hours. The 1 IU dose of TSH, previously frozen for up to 200 days, induced increases in serum total thyroxine concentration over baseline at four and six hours that were not significantly different from those resulting from the use of the higher dose of fresh TSH. In all test groups, there were no statistically significant differences between total thyroxine concentrations at four and six hours post-TSH administration. It was concluded that an adequate TSH response can be achieved with the use of 1 IU of TSH/dog for clinically normal dogs between 29.0 kg and 41.6 kg body weight, even if this TSH has been frozen at -20 degrees C for up to 200 days. Further, blood collection can be performed at any time between four and six hours. Similar studies are needed to evaluate this new protocol in hypothyroid dogs and euthyroid dogs suffering nonthyroidal systemic diseases.

Effects of flumazenil on cholecystokinin-tetrapeptide-induced panic symptoms in healthy volunteers

The neuropeptide cholecystokinin-tetrapeptide (CCK-4) has potent anxiogenic action in human and animal subjects. On the basis of prior work which demonstrated that benzodiazepine (BZD) receptor agonists antagonized CCK-induced excitation of rat hippocampal neurons we studied whether BZD receptors mediated the anxiogenic effect of CCK-4. To examine this possibility we determined whether the BZD receptor antagonist flumazenil could antagonize the effects of CCK-4 (50 micrograms) in healthy volunteers. Thirty subjects (10 females; 20 males) were pretreated with flumazenil (2 mg in saline) or placebo (0.9% NaCl in water) 15 min prior to CCK-4 challenge in a randomized double-blind crossover design. Flumazenil had no impact on the behavioral and cardiovascular effects of CCK-4, suggesting that BZD receptors do not mediate the anxiogenic action of CCK-4. The influence of GABA and non-GABA-related mechanisms on response to CCK-4 remains to be considered.

Evaluation of an in-office allergy screening test in nonatopic dogs having various intestinal parasites

An in-office allergy screening kit was evaluated in 10 dogs that had no clinical signs of atopy but had various intestinal parasites. All 10 dogs had a positive reaction to the dust mite Dermatophagoïdes farinae, and four dogs had positive reactions to at least one other group of allergens. The kit as presently marketed gives numerous false positive results in parasitized nonatopic dogs.

Genetic heterogeneity of gene defects responsible for familial Alzheimer disease

Inherited Alzheimer's disease is a genetically heterogeneous disorder that involves gene defects on at least five chromosomal loci. Three of these loci have been found by genetic linkage studies to reside on chromosomes 21, 19, and 14. On chromosomes 21, the gene encoding the precursor protein of Alzheimer-associated amyloid (APP) has been shown to contain several mutations in exons 16 and 17 which account for roughly 2-3% of familial Alzheimer's disease (FAD). The other loci include what appears to be a susceptibility gene on chromosome 19 associated with late-onset (> 65 years) FAD, and a major early-onset FAD gene defect on the long arm of chromosome 14. In other early- and late-onset FAD kindreds, the gene defects involved do not appear to be linked to any of these three loci, indicating the existence of additional and as of yet unlocalized FAD genes. This review provides a historical perspective of the search for FAD gene defects and summarizes the progress made in world-wide attempts to isolate and characterize the genes responsible for this disorder.

Use of tetracycline and niacinamide for treatment of autoimmune skin disease in 31 dogs

A combination of niacinamide and tetracycline was used to treat 31 dogs with various autoimmune skin diseases (discoid lupus erythematosus, pemphigus foliaceus, pemphigus erythematosus, and bullous pemphigoid). Of the 20 dogs with discoid lupus erythematosus, 70% had excellent or good response to treatment. Serious side effects were not noticed in any dog.

Seasonality and variability of the interestrous interval in the bitch

Records from two breeding colonies (A and B) located near each other were analyzed for this experiment. Colony A consisted of 19 bitches (8 Maltese, 5 Yorkshire, 3 Lhasa Apso, and 3 Bouvier des Flandres), while Colony B consisted of 48 Beagle bitches. A total of 126 interestrous intervals (141 estrous cycles) from Colony A were reviewed to quantitate the variability of the interestrous interval. Analysis of variance showed that the degree of variation of the estrous cycle length within bitches (65%) was about twice the degree of variation of means of the estrous cycle length among bitches (35%). It was found that the estrous cycle length is extremely variable, and it cannot be used to predict the next estrus in a single bitch, although some bitches were very consistent. The seasonal and monthly distribution of estrous cycles throughout the year was also analyzed from bitches kept in Colonies A and B for a total of 210 estrous cycles. The data were collected over a four-year period. A seasonal pattern was observed when the cumulative distributions over years were analyzed. A higher frequency of estrous cycles was observed during winter and summer. This seasonality pattern was not observed when individual years were analyzed separately. However, the overall probability that an estrus would occur at any month of the year was the same for each month (1/12) when cumulative distribution over years were analyzed.

A survey of canine and feline skin disorders seen in a university practice: Small Animal Clinic, University of Montréal, Saint-Hyacinthe, Québec (1987-1988)

Dermatological disorders accounted for 18.8% and 15.2%, respectively, of all the dogs and cats examined at the Small Animal Clinic, University of Montreal, Saint-Hyacinthe, during a one-year period. In dogs, the most common groups of dermatological disorders encountered were bacterial folliculitis and furunculosis, allergic dermatitis, endocrinopathy, neoplasia, ectoparasitism, and immune-mediated dermatitis. The most common primary final diagnoses were bacterial folliculitis and furunculosis, atopy, food hypersensitivity, flea bite hypersensitivity, hyperadrenocorticism, and hypothyroidism. Breed predispositions were found for several canine dermatoses: bacterial folliculitis and furunculosis (collie, German shepherd, golden retriever, Newfoundland), atopy (boxer, golden retriever), food hypersensitivity (boxer, German shepherd), hyperadrenocorticism (miniature poodle), hypothyroidism (Doberman pinscher, Gordon setter), castration-responsive alopecia (chow chow), demodicosis (Old English sheepdog), and idiopathic pruritus (pit bull terrier).In cats, the most common dermatoses were abscesses, otodectic mange, cheyletiellosis, flea bite hypersensitivity, atopy, flea infestation, neoplasia, and food hypersensitivity. Himalayan and Persian cats accounted for 50% of the cases of cheyletiellosis and 75% of the cases of dermatophytosis, respectively. Hereditary primary seborrhea oleosa was seen only in Persian cats.

Sterile nodular panniculitis in five horses

Sterile nodular panniculitis was diagnosed in 5 horses. Physical abnormalities were predominantly limited to cutaneous changes, consisting of multiple subcutaneous nodules that had a tendency to wax and wane over time and were commonly distributed over the trunk, neck, and proximal portion of the limbs. In each horse, the diagnosis was confirmed by excisional biopsy of a nodule and by exclusion of infective causes of panniculitis on the basis of negative culture results and special stain application to skin specimens. Treatment with immunosuppressive doses of glucocorticoids was curative in 1 horse, was required on a daily or alternate-day schedule in 2 others to keep the skin clear, and had no effect on the disease in the remaining 2 horses.

Squamous cell carcinoma of the nail bed in three related giant schnauzers

Three black giant schnauzers, mother, daughter and son, developed single or multiple primary squamous cell carcinomas of the nail bed between the ages of nine and 12 years. The clinicopathological findings are described. Radiographic evidence of osteolysis of the third phalanx, especially in a middle-aged to older large-breed, black dog would warrant the amputation and histopathological examination of the digit because of the likelihood of squamous cell carcinomas.

Calcinosis cutis secondary to percutaneous penetration of calcium carbonate in a Dalmatian

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Hyperadrenocorticism in association with an adrenocortical adenoma in a pet ferret

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Alopecia areata (pelade) in a cow

A case of alopecia areata (pelade) is described in a cow. Alopecia areata is a rare idiopathic dermatosis of cattle. It is characterized by asymptomatic, solitary or multiple, annular areas of noninflammatory alopecia. Scrapings and cultures are negative, and the diagnosis is confirmed by skin biopsies taken from early lesions, which reveal accumulations of lymphocytes around the bulbs of anagen hair follicles. There is no known effective and practical treatment for affected cattle. The dermatitis is a cosmetic problem, but does not seem to affect general health and production, and spontaneous remission may occur.

Efficacy of Ivermectin against Cheyletiella yasguri Infestation in Dogs

Twenty adult dogs (11 Cocker spaniels and 9 miniature Poodles) with naturally occurring cheyletiellosis were treated twice, at a three-week interval, with subcutaneous injections of ivermectin at the dose rate of 300 mug/kg. Ivermectin proved to be very effective against Cheyletiella yasguri infestation in dogs. All treated animals were completely cured after one or two treatments. No adverse reactions were noted. Ivermectin should be avoided in Collies and Collie crosses.