Non-cardiogenic pulmonary oedema complicating balloon valvuloplasty and stent angioplasty of severe pulmonary valve stenosis in four dogs

In dogs, balloon valvuloplasty is considered the treatment of choice for severe pulmonary valve stenosis, and this technique is currently performed routinely in specialist referral practices with low morbidity and mortality. Stent angioplasty has also been recently proposed as a viable treatment option. The present case series describes the clinical course of four dogs with severe pulmonary valve stenosis, treated with balloon valvuloplasty or stent angioplasty at four different institutions, which developed non-cardiogenic pulmonary oedema perioperatively after apparently successful dilation of the pulmonary valve. In three cases, there was evidence of some degree of pulmonary hypertension before ballooning. Despite intensive care, the complication proved fatal in three cases. Clinicians should therefore be aware of this life-threatening complication, previously undescribed in dogs.

Validation of the acute cholecystectomy rate as a quality indicator for emergency general surgery using the SWORD database

INTRODUCTION

Despite an increasing emphasis on data-driven quality improvement, few validated quality indicators for emergency surgical services have been published. The aims of this study therefore were: 1) to investigate whether the acute cholecystectomy rate is a valid process indicator; and 2) to use this rate to examine variation in the provision of acute cholecystectomy in England.

MATERIALS AND METHODS

The Surgical Workload and Outcomes Research Database (SWORD), derived from the Hospital Episode Statistics database, was interrogated for the 2012-2017 financial years. All adult patients admitted with acute biliary pancreatitis, cholecystitis or biliary colic to hospitals in England were included and the acute cholecystectomy rate in each one examined.

RESULTS

A total of 328,789 patients were included, of whom 42,642 (12.9%) underwent an acute cholecystectomy. The acute cholecystectomy rate varied significantly between hospitals, with the overall rate ranging from 1.2% to 36.5%. This variation was consistent across all disease groupings and time periods, and was independent of the annual number of procedures performed by each NHS trust. In 41 (29.9%) trusts, fewer than one in ten patients with acute gallbladder disease underwent cholecystectomy within two weeks.

CONCLUSIONS

The acute cholecystectomy rate is easily measurable using routine administrative datasets, modifiable by local services and has a strong evidence base linking it to patient outcomes. We therefore advocate that it is an ideal process indicator that should be used in quality monitoring and improvement. Using it, we identified significant variation in the quality of care for acute biliary disease in England.

Breed does not affect the association between murmur intensity and disease severity in dogs with pulmonic or subaortic stenosis

OBJECTIVES

To determine whether breed affects the ability of murmur intensity to predict the severity of stenosis in dogs with pulmonic stenosis or subaortic stenosis.

MATERIALS AND METHODS

Retrospective multi-investigator study of dogs with pulmonic stenosis or subaortic stenosis. Murmur intensity, assessed by a four-level classification scheme, was compared with echocardiographically-determined pressure gradient across the affected valve. Breeds represented by at least 10 dogs at any murmur intensity were compared to determine the effect, if any, of breed.

RESULTS

A total of 1088 dogs (520 with pulmonic stenosis and 568 with subaortic stenosis, representing 106 breeds and the mixed breed group) were included; 208 dogs had soft, 210 had moderate, 283 had loud and 387 had palpable murmurs. Fifteen breeds were represented by at least 10 dogs: five breeds with at least 10 dogs had soft murmurs (132 dogs), nine breeds had moderate murmurs (149 dogs), 10 breeds had loud murmurs (188 dogs), and 11 breeds had palpable murmurs (286 dogs). No breeds differed in stenosis severity from any other breeds within any murmur grade. Post hoc power calculations suggested that we would have been able to detect at least a moderate or large effect size, had one existed. Several dogs with soft murmurs had more-than-mild disease severity.

CLINICAL SIGNIFICANCE

Despite anecdotally perceived differences in the detection of heart murmurs between breeds, which have been proposed to potentially affect the interpretation of stenosis severity, we found no obvious breed effect in the ability to predict severity of stenosis.

Variation in outcomes and use of laparoscopy in elective inguinal hernia repair

Background

The early outcomes of inguinal hernia repair in routine practice and the extent to which the laparoscopic approach is used are unknown. The aims of this study were to identify national benchmarks for early reoperation and readmission rates, to identify the degree to which the laparoscopic approach is used for elective hernia surgery in England, and to identify whether there is any variation nationally.

Methods

All adults who underwent publically funded elective inguinal hernia repair in England during the six financial years from 2011–2012 to 2016–2017 were identified in the Surgeon's Workload Outcomes and Research Database (SWORD). Patients were grouped according to whether they had a primary, recurrent or bilateral hernia, and according to sex. Overall rates of readmission, reoperation and laparoscopic approach were calculated, and variation was assessed using funnel plots.

Results

Some 390 777 patients were included. Overall, 11 448 patients (2·9 per cent) were readmitted to hospital as an emergency within 30 days of surgery and 2872 (0·7 per cent) had a further operation. Laparoscopic repair was performed for 65·5 per cent of bilateral inguinal hernias compared with 17·1 per cent of primary unilateral inguinal hernias, 31·3 per cent of recurrent hernia repairs and 14·0 per cent of primary unilateral hernias in women. The unadjusted readmission, reoperation and laparoscopy rates varied significantly between hospitals.

Conclusion

The likelihood of a patient being readmitted to hospital, having an emergency reoperation or undergoing laparoscopic inguinal hernia repair varies significantly depending on the hospital to which they are referred. Hospitals and service commissioners should use this data to drive service improvement and reduce this variation.

Intelligent Data Analysis for Knowl edge Discovery, Patient Monitoring and Quality Assessment

Objective: To introduce the focus theme of Methods of Information in Medicine on Intelligent Data Analysis for Knowledge Discovery, Patient Monitoring and Quality Assessment.

Methods: Based on two workshops on Intelligent Data Analysis in bioMedicine (IDAMAP) held in Washington, DC, USA (2010) and Bled, Slovenia (2011), six authors were invited to write full papers for the focus theme. Each paper was throughly reviewed by anonymous referees and revised one or more times by the authors.

Results: The selected papers cover four ongoing and emerging topics in Intelligent Data Analysis (IDA), being i) systems biology and metabolic pathway modelling; ii) gene expression data modelling; iii) signal processing from in-home monitoring systems; and iv) quality of care assessment. Each of these topics is discussed in detail to introduce the papers to the reader.

Conclusion: The development and application of IDA methods in biomedicine is an active area of research which continues to blend with other subfields of medical informatics. As data become increasingly ubiquitous in the biomedical domain, the demand for fast, smart and flexible data analysis methods is undiminished.

Degenerative Valvular Disease in the Cavalier King Charles Spaniel: Results of the UK Breed Scheme 1991-2010

Background

Cavalier King Charles spaniels (CKCSs) are predisposed to degenerative mitral valve disease (DMVD) and studies have indicated a genetic cause.

Animals

A total of 8,860 CKCSs were examined at shows or private clinics from 1991 to 2010.

Objectives

To analyze the effects of a breed scheme for CKCS on the age at which a murmur consistent with DMVD was first detected.

Methods

The presence or absence of a murmur consistent with mitral regurgitation was noted and age a murmur was first detected recorded.

Results

A total of 16,887 examinations were performed on 8,860 dogs. The median age dogs developed a murmur were slightly younger in male than female dogs (7.8 versus 8.3 years, 95% confidence interval [CI] 7.4–8.1 versus 8.0–8.4, P < .001) and cardiologists detected murmurs in younger dogs than did general practitioner (GP) veterinary surgeons (7.2 versus 8.6 years, 95% CI 7.0–7.4 versus 8.3–8.7 P < .001). In bitches examined by GP vets during the study, there was a significantly increased age of detection of murmurs over time (8.6–9.2 years, 95% CI 8.3–9.1 and 8.5–10.9, P = .001) but not for male dogs examined by GP vets or dogs of either sex examined by cardiologists.

Conclusions and Clinical Importance

This study suggests that the age incidence of murmurs associated with DMVD might be increased by application of breeding guidelines based on auscultation alone. This benefit was only seen in a subgroup and compliance of breeders with this voluntary scheme was poor.

Screening of anti-mycobacterial compounds in a naturally infected zebrafish larvae model

OBJECTIVES

Mycobacterium tuberculosis is a deadly human pathogen that causes the lung disease TB. M. tuberculosis latently infects a third of the world's population, resulting in ∼1.5 million deaths per year. Due to the difficulties and expense of carrying out animal drug trials using M. tuberculosis and rodents, infections of the zebrafish Danio rerio with Mycobacterium marinum have become a useful surrogate. However, the infection methods described to date require specialized equipment and a high level of operator expertise.

METHODS

We investigated whether zebrafish larvae could be naturally infected with bioluminescently labelled M. marinum by immersion, and whether infected larvae could be used for rapid screening of anti-mycobacterial compounds using bioluminescence. We used rifampicin and a variety of nitroimidazole-based next-generation and experimental anti-mycobacterial drugs, selected for their wide range of potencies against M. tuberculosis, to validate this model for anti-mycobacterial drug discovery.

RESULTS

We observed that five of the six treatments (rifampicin, pretomanid, delamanid, SN30488 and SN30527) significantly reduced the bioluminescent signal from M. marinum within naturally infected zebrafish larvae. Importantly, these same five treatments also retarded the growth of M. tuberculosis in vitro. In contrast, only three of the six treatments tested (rifampicin, delamanid and SN30527) retarded the growth of M. marinum in vitro.

CONCLUSIONS

We have demonstrated that zebrafish larvae naturally infected with bioluminescent M. marinum M can be used for the rapid screening of anti-mycobacterial compounds with readily available equipment and limited expertise. The result is an assay that can be carried out by a wide variety of laboratories for minimal cost and without high levels of zebrafish expertise.

Longitudinal analysis of quality of life, clinical, radiographic, echocardiographic, and laboratory variables in dogs with myxomatous mitral valve disease receiving pimobendan or benazepril: the QUEST study

BACKGROUND

Myxomatous mitral valve disease (MMVD) is an important cause of morbidity and mortality in dogs.

OBJECTIVES

To compare, throughout the period of follow-up of dogs that had not yet reached the primary endpoint, the longitudinal effects of pimobendan versus benazepril hydrochloride treatment on quality-of-life (QoL) variables, concomitant congestive heart failure (CHF) treatment, and other outcome variables in dogs suffering from CHF secondary to MMVD.

ANIMALS

A total of 260 dogs in CHF because of MMVD.

METHODS

A prospective single-blinded study with dogs randomized to receive pimobendan (0.4-0.6 mg/kg/day) or benazepril hydrochloride (0.25-1.0 mg/kg/day). Differences in outcome variables and time to intensification of CHF treatment were compared.

RESULTS

A total of 124 dogs were randomized to pimobendan and 128 to benazepril. No difference was found between groups in QoL variables during the trial. Time from inclusion to 1st intensification of CHF treatment was longer in the pimobendan group (pimobendan 98 days, IQR 30-276 days versus benazepril 59 days, IQR 11-121 days; P = .0005). Postinclusion, dogs in the pimobendan group had smaller heart size based on VHS score (P = .013) and left ventricular diastolic (P = .035) and systolic (P = .0044) dimensions, higher body temperature (P = .030), serum sodium (P = .0027), and total protein (P = .0003) concentrations, and packed cell volume (P = .030). Incidence of arrhythmias was similar in treatment groups.

CONCLUSIONS AND CLINICAL IMPORTANCE

Pimobendan versus benazepril resulted in similar QoL during the study, but conferred increased time before intensification of CHF treatment. Pimobendan treatment resulted in smaller heart size, higher body temperature, and less retention of free water.

Total viable bacterial count using a real time all-fibre spectroscopic system

Rapid, accurate and sensitive enumeration of bacterial populations in the natural environment is an essential task for many research fields. Widely used standard methods for counting bacteria such as heterotrophic plate count require 1 to 8 days of incubation time for limited accuracy, while more accurate and rapid techniques are often expensive and may require bulky equipment. In the present study, we have developed a computerized optical prototype for bacterial detection. The goal of this research was to estimate the potential of this optical system for Total Viable Bacterial Count in water. For this purpose, we tested water batches with different microbiological content. Bacterial detection was based on fluorescence enhanced by nucleic acid staining. High sensitivity was achieved by a stable diode pumped solid state laser, sensitive CCD spectrometer and in situ excitation and signal collection. The results have shown that the bacterial count from different water origins using our optical setup along with multivariate analysis presents a higher accuracy and a shorter detection time compared to standard methods. For example, in a case where the fluorescence signal is calibrated to the water batch regression line, the relative standard deviation of the optical system enumeration varies between 21 and 36%, while that of the heterotropic plate count counterpart varies between 41 and 59%. In summary, we conclude that the all-fibre optical system may offer the following advantages over conventional methods: near real time examinations, portability, sensitivity, accuracy and ability to detect 10(2) to 10(8) CFU per ml bacterial concentrations.

Pathway based microarray analysis, utilising enzyme compounds and cascade events

BACKGROUND

Pathway based microarray analysis is an effort to integrate microarray and pathway data in a holistic analytical approach, looking for coordinated changes in the expression of sets of genes forming pathways. However, it has been observed that the results produced are often cryptic, with cases of closely related genes in a pathway showing quite variable, even opposing expression.

OBJECTIVES

We propose a methodology to identify the state of activation of individual pathways, based on our hypothesis that gene members of many pathways or modules exhibit differential expression that results from their contribution to any combination of all their constituent pathways. Therefore, the observed expression of such a gene does not necessarily imply the activation state of a given pathway where its product participates, but reflects the net expression resulting from its participation in all its constituent pathways.

METHODS

Firstly, in an effort to validate the hypothesis, we split the genes into two groups; single and multi-membership. We then determined and compared the proportion of differentially expressed genes in each group, for each experiment. In addition, we estimated the cumulative binomial probability of observing as many or more expressed genes in each group, in each experiment, simply by chance. Second, we propose a hill climbing methodology, aiming to maximise the agreement of gene expression per module.

RESULTS

We detected more frequent expression of multi-membership genes and significantly lower probabilities of observing such a high proportion of differentially expressed multi-membership genes, as the one present in the dataset. The algorithm was able to correctly identify the state of activation of the KEGG glycolysis and gluconeogenesis modules, using a number of Saccharomyces cerevisiae datasets. We show that the result is equivalent to the best solution found following exhaustive search.

CONCLUSIONS

The proposed method takes into account the multi-membership nature of genes and our knowledge of the competitive nature of our exemplar modules, revealing the state of activity of a pathway.

Acute appendicitis within a recurrent inguinal hernia presenting as epididymo-orchitis

We report the first case of appendicitis within a recurrent inguinal hernia, more unique in its presentation as epididymo-orchitis. A 61-year old male presented with right testicular pain, erythematous scrotum and raised inflammatory markers. He previously had recurrent left epididymo-orchitis and right inguinal hernia repair. A diagnosis of epididymo-orchitis was made but CT was performed which diagnosed acute appendicitis within a recurrent inguinal hernia entering the scrotum. This was confirmed intra-operatively with a distal inflamed appendix segment passing beyond the medial border of the exposed mesh. Correct pre-operative CT diagnosis requires high index of suspicion even with innocuous testicular symptoms. CT reduces misdiagnosis which is associated with significant morbidity, and also aids in planning surgical approach. The only other case of acute appendicitis presenting with testicular symptoms was diagnosed only during scrotal exploration necessitating further laparotomy. The appendix entrapment beyond the mesh could suggest an alternative aetiology of mesh-related appendicitis.

An evaluation of four CT-MRI co-registration techniques for radiotherapy treatment planning of prone rectal cancer patients

OBJECTIVES

MRI is the preferred staging modality for rectal carcinoma patients. This work assesses the CT-MRI co-registration accuracy of four commercial rigid-body techniques for external beam radiotherapy treatment planning for patients treated in the prone position without fiducial markers.

METHODS

17 patients with biopsy-proven rectal carcinoma were scanned with CT and MRI in the prone position without the use of fiducial markers. A reference co-registration was performed by consensus of a radiologist and two physicists. This was compared with two automated and two manual techniques on two separate treatment planning systems. Accuracy and reproducibility were analysed using a measure of target registration error (TRE) that was based on the average distance of the mis-registration between vertices of the clinically relevant gross tumour volume as delineated on the CT image.

RESULTS

An automated technique achieved the greatest accuracy, with a TRE of 2.3 mm. Both automated techniques demonstrated perfect reproducibility and were significantly faster than their manual counterparts. There was a significant difference in TRE between registrations performed on the two planning systems, but there were no significant differences between the manual and automated techniques.

CONCLUSION

For patients with rectal cancer, MRI acquired in the prone treatment position without fiducial markers can be accurately registered with planning CT. An automated registration technique offered a fast and accurate solution with associated uncertainties within acceptable treatment planning limits.

Intelligent data analysis for knowledge discovery, patient monitoring and quality assessment

OBJECTIVE

To introduce the focus theme of Methods of Information in Medicine on Intelligent Data Analysis for Knowledge Discovery, Patient Monitoring and Quality Assessment.

METHODS

Based on two workshops on Intelligent Data Analysis in bioMedicine (IDAMAP) held in Washington, DC, USA (2010) and Bled, Slovenia (2011), six authors were invited to write full papers for the focus theme. Each paper was throughly reviewed by anonymous referees and revised one or more times by the authors.

RESULTS

The selected papers cover four ongoing and emerging topics in Intelligent Data Analysis (IDA), being i) systems biology and metabolic pathway modelling; ii) gene expression data modelling; iii) signal processing from in-home monitoring systems; and iv) quality of care assessment. Each of these topics is discussed in detail to introduce the papers to the reader.

CONCLUSION

The development and application of IDA methods in biomedicine is an active area of research which continues to blend with other subfields of medical informatics. As data become increasingly ubiquitous in the biomedical domain, the demand for fast, smart and flexible data analysis methods is undiminished.

Balloon valvuloplasty for treatment of pulmonic stenosis in English Bulldogs with an aberrant coronary artery

BACKGROUND

English Bulldogs (EB) with pulmonic stenosis (PS) sometimes have an aberrant coronary artery (CA) type R2A encircling the pulmonary artery (PA). Balloon valvuloplasty (BV) is treatment of choice for severe PS, but is considered to be contraindicated in dogs with aberrant CA.

HYPOTHESIS

Conservative BV in EB with aberrant CA is safe and improves clinical signs and quality of life.

ANIMALS

Four client-owned EB with severe PS were retrospectively reviewed/analysed.

METHODS

Retrospective study: Case records, echocardiography, BV, and follow-up investigations of EB diagnosed with severe PS and treated with BV were reviewed. The ratios of PA to aortic (Ao) velocity time integral (VTI) were calculated to assess progression/improvement of PS.

RESULTS

An aberrant CA was confirmed on angiography in all EB. Conservative BV was performed, using a balloon of the size of the PA annulus or smaller (0.6-1 x PA annulus size). All dogs survived the procedure, but only a mild reduction in pressure gradient was achieved. There was an improvement in PA to Ao VTI in 3 of 4 dogs (P < or = .017), which were free of evidence of congestive heart failure (CHF) 5, 10, and 15 months after BV. One dog that had right-sided CHF when BV was performed died due to progressive right-sided CHF within 3 months.

CONCLUSIONS

Conservative BV in EB might be safe and might improve quality and quantity of life.

Aetiology and outcome in 90 cats presenting with dyspnoea in a referral population

Objectives:Dyspnoea is an unspecific severe presenting sign, which can be life threatening and requires prompt treatment. Dyspnoeic cats often have significant underlying disease. Underlying aetiologies in cats that presented with dyspnoea were reviewed, and associations with patient signalment and outcome were investigated.

Methods:The case records of 90 dyspnoeic cats were retrospectively reviewed and separated into different groups depending on aetiology (cardiac, respiratory, neoplastic and trauma). Duration of clinical signs, presentation, hospitalisation length and survival were analysed.

Results:Cardiac (38 per cent), respiratory (32 per cent) and neoplastic (20 per cent) diseases were common causes of feline dyspnoea. Cats with respiratory causes had longer duration of clinical signs (P<0·001) before presentation. Cats with neoplasia were significantly older (P<0·001). No significant difference in respiratory rates was present between the groups (P = 0·154). High heart rates (P<0·001) and abnormalities on cardiac auscultation were more likely in the cardiac group.

Clinical Significance:Frequent causes of dyspnoea in cats were cardiac disease followed by respiratory causes and neoplastic conditions. Heart rate on presentation and presence of heart murmurs or gallops are useful to identify cardiac causes. Improved proportion surviving was found in the respiratory group (P = 0·027), whereas cats with neoplasia had the worst outcome.

Cardiac troponin I as a marker for severity and prognosis of cardiac disease in dogs

The use of cardiac troponin I (cTnI) to assess the severity of disease and prognosis in 120 dogs presented for cardiac evaluation was analysed. cTnI concentrations were measured using a commercially available assay. Dogs were placed into three groups: group 1, cTnI0.15ng/mL; group 2, cTnI 0.151-1.0ng/mL; group 3, cTnI>1.01ng/mL. Dogs in group 1 were significantly younger (P<0.0001) and had no or stable cardiac diseases and longest survival times, whereas those in groups 2 and 3 had severe cardiac diseases and significantly reduced survival times (P<0.0001). Thirty dogs with initially increased cTnI concentrations had a repeat assay less than 2months later with significant reductions in cTnI concentrations (P=0.005). Initial cTnI concentrations could not differentiate dogs that survived in group 3 from those that did not. However, dogs that survived showed significant cTnI reductions (P=0.015) in the repeated assay in contrast to the dogs that died (P=0.22). It was concluded that cTnI is useful in assessing the prognosis and severity of cardiac diseases in dogs, and progression and response to treatment can be assessed by repeat sampling. cTnI concentrations >1.0ng/mL and persistent increases in cTnI concentrations are indicators of a poor prognosis in dogs with cardiac disease.

Implantable loop recorders: a viable diagnostic tool in veterinary medicine

OBJECTIVE

The purpose of this study was to investigate whether implantable loop recorders could be used in the diagnosis of unexplained collapse in dogs.

METHODS

The medical records of six dogs presented to the University of Liverpool Small Animal Teaching Hospital between May 2003 and October 2006 for further evaluation of intermittent syncopal episodes, collapse or episodic weakness, were reviewed. All these dogs underwent standard investigations and had implantable loop recorders placed.

RESULTS

A provisional diagnosis of supraventricular tachycardia was made in one dog, and diagnoses of exclusion of arrhythmogenic right ventricular cardiomyopathy and idiopathic epilepsy was made in two dogs. One dog suffered no further syncopal episodes, a diagnosis was not reached in another dog and the final dog was lost to follow-up.

CLINICAL SIGNIFICANCE

The implantable loop recorder can be used successfully for the diagnosis of unexplained collapse in dogs.

Canine dynamic left ventricular outflow tract obstruction: assessment of myocardial function and clinical outcome

OBJECTIVE

The aims of this study were (i) to evaluate echocardiographic findings and myocardial function including pulsed wave tissue Doppler imaging in dogs with naturally occurring dynamic left ventricular outflow tract obstruction and (ii) to investigate the clinical outcome and response to therapy in these dogs.

METHODS

Two cases were retrospectively reviewed and three cases were prospectively evaluated including clinical findings, diagnostic test results (including standard Doppler echocardiography and pulsed wave tissue Doppler imaging), response to treatment and outcome. The two retrospective cases received no treatment. Other cases were treated with a beta-blocker.

RESULTS

All dogs had a variable intensity left apical systolic murmur. Concentric left ventricular hypertrophy, systolic anterior motion of the mitral valve and scimitar-shaped left ventricular outflow tract Doppler flow profile were present in all cases. Pulsed wave tissue Doppler imaging interrogation of the interventricular septum revealed E'/A' reversal in all but one patient. Regression of left ventricular hypertrophy and total resolution of the dynamic left ventricular outflow tract obstruction were observed in all cases.

CLINICAL SIGNIFICANCE

Young dogs are affected with a possible terrier breed predisposition. Dynamic left ventricular outflow tract obstruction may be distinguished from canine hypertrophic cardiomyopathy as progressive resolution of echocardiographic abnormalities was documented. Pulsed wave tissue Doppler imaging abnormalities provide further evidence for significant diastolic dysfunction associated with the hypertrophy.

Effect of pimobendan or benazepril hydrochloride on survival times in dogs with congestive heart failure caused by naturally occurring myxomatous mitral valve disease: the QUEST study

BACKGROUND

Myxomatous mitral valve disease (MMVD) continues to be an important cause of morbidity and mortality in geriatric dogs despite conventional therapy.

HYPOTHESIS

Pimobendan in addition to conventional therapy will extend time to sudden cardiac death, euthanasia for cardiac reasons, or treatment failure when compared with conventional therapy plus benazepril in dogs with congestive heart failure (CHF) attributable to MMVD.

ANIMALS

Two hundred and sixty client-owned dogs in CHF caused by MMVD were recruited from 28 centers in Europe, Canada, and Australia.

METHODS

A prospective single-blinded study with dogs randomized to PO receive pimobendan (0.4-0.6 mg/kg/d) or benazepril hydrochloride (0.25-1.0 mg/kg/d). The primary endpoint was a composite of cardiac death, euthanized for heart failure, or treatment failure.

RESULTS

Eight dogs were excluded from analysis. One hundred and twenty-four dogs were randomized to pimobendan and 128 to benazepril. One hundred and ninety dogs reached the primary endpoint; the median time was 188 days (267 days for pimobendan, 140 days for benazepril hazard ratio = 0.688, 95% confidence limits [CL]=0.516-0.916, P= .0099). The benefit of pimobendan persisted after adjusting for all baseline variables. A longer time to reach the endpoint was also associated with being a Cavalier King Charles Spaniel, requiring a lower furosemide dose, and having a higher creatinine concentration. Increases in several indicators of cardiac enlargement (left atrial to aortic root ratio, vertebral heart scale, and percentage increase in left ventricular internal diameter in systole) were associated with a shorter time to endpoint, as was a worse tolerance for exercise.

CONCLUSIONS AND CLINICAL IMPORTANCE

Pimobendan plus conventional therapy prolongs time to sudden death, euthanasia for cardiac reasons, or treatment failure in dogs with CHF caused by MMVD compared with benazepril plus conventional therapy.

Rapid production of retroviruses for efficient gene delivery to mammalian cells using 293T cell-based systems

This unit details the applications of one of the more common retroviral packaging systems, based on the highly transfectable 293T cell. The packaging system employs the use of the Phoenix cell lines. Calcium phosphate-mediated transfection is described for efficient introduction of retroviral vector plasmid DNA into the cells to generate high yields of virion-containing supernatant. An alternate protocol describes a method for transfecting retroviruses that contain a vesicular stomatitis virus G (VSV G) protein. Such virions are said to be "pseudotyped" with VSV G glycoprotein. Support protocols provide a simple method for concentrating VSV-G-pseudotyped retroviruses, as well as methods for culturing, cryopreserving, thawing, and drug selecting the Phoenix packaging cell lines. Finally, several methods for transfecting adherent or suspension cells with retroviruses are described.

Modeling Cd2+ sorption onto ferrihydrite in the presence of phthalic acid

Cadmium sorption by ferrihydrite in the presence of phthalic acid was examined over a range of pH (4.0 approximately 8.5) conditions and sorbate/sorbent ratios. The presence of phthalic acid enhanced Cd(2+) sorption by forming ternary complexes on ferrihydrite surface, especially at low pH, but for high pH and high total organic ligand/Fe(mmol/mol) ratios, it decreased Cd(2+) sorption onto ferrihydrite by forming soluble complexes with the phthalate in solution. In binary systems, Cd(2+) and phthalic acid sorption by ferrihydrite was well reproduced using the diffuse layer model with sorption constants derived from the experimental data. Prediction using the optimised binary sorption constants for Cd(2+) sorption onto ferrihydrite in the presence of phthalic was poor and achieving a good fit required the inclusion of two additional ternary complexes.

Management of cor triatriatum dexter by balloon dilatation in three dogs

Two dogs, one immature and one adult, were presented with a history of progressive ascites. In a third, immature dog, increasing exercise intolerance had been noted. Echocardiography demonstrated a partition in the right atrium (cor triatriatum dexter) and echocontrast studies documented normal flow from the cranial vena cava into the right atrium and ventricle. A saphenous vein contrast study demonstrated flow from the caudal vena cava into an accessory right atrial chamber (sinus venarum). The sinus venarum communicated with the true right atrium via a small defect in the atrial membrane in one dog, and additionally with the left atrium via a right-to-left shunting foramen ovale in the other dogs. All defects were visualised on angiographic studies by selective catheterisation of the caudal vena cava via the femoral vein. Balloon dilatation of the defect was then performed using a small followed by a larger balloon angioplasty catheter to enlarge the defect in the atrial membrane. Clinical signs improved within days and were sustained in the long-term in all cases.

EGFR amplification and lack of activating mutations in metaplastic breast carcinomas

Metaplastic breast carcinomas are reported to harbour epidermal growth factor receptor (EGFR) overexpression in up to 80% of the cases, but EGFR gene amplification is the underlying genetic mechanism in around one-third of these. In this study, EGFR gene amplification as defined by chromogenic in situ hybridization and protein overexpression was examined in a cohort of 47 metaplastic breast carcinomas. Furthermore, the presence of activating EGFR mutations in exons 18, 19, 20, and 21 was investigated. Thirty-two cases showed EGFR overexpression and of these, 11 (34%) harboured EGFR gene amplification. In addition, EGFR amplification showed a statistically significant association with EGFR overexpression (p < 0.0094) and was restricted to carcinomas with homologous metaplasia. Ten cases, five with and five without EGFR amplification, were subjected to microarray-based CGH, which demonstrated that EGFR copy number gain may occur by amplification of a discrete genomic region or by gains of the short arm of chromosome 7 with a breakpoint near the EGFR gene locus, the minimal region of amplification mapping to EGFR, LANCL2, and SEC61G. No activating EGFR mutations were identified, suggesting that this is unlikely to be a common alternative underlying genetic mechanism for EGFR expression in metaplastic breast carcinomas. Given that metaplastic breast carcinomas are resistant to conventional chemotherapy or hormone therapy regimens and that tumours with EGFR amplification are reported to be sensitive to EGFR tyrosine kinase inhibitors, these findings indicate that further studies are warranted to explore EGFR tyrosine kinase inhibitors as potential therapeutic agents for metaplastic breast carcinomas harbouring amplification of 7p11.2.

Is the pelvic organ prolapse quantification system (POPQ) being used? A survey of members of the International Continence Society (ICS) and the American Urogynecologic Society (AUGS)

The authors performed a web-based questionnaire survey of 667 members of the ICS and AUGS to determine the current use of the pelvic organ prolapse quantification (POPQ) system by members of the professional societies which have advocated its use. Three hundred and eighty (57%) gynecologists responded. This international survey shows that only 40.2% of ICS and AUGS members who responded routinely use the POPQ system in their clinical practice and provides information on the most common reasons for not using it. The results highlight some of the concerns regarding the complex nature of the system and its acceptance and use by specialists worldwide. It also suggests the need for a simplified version of the classification system that is user-friendly and can be adopted by all practitioners.

Treatment of toxic epidermal necrolysis with intravenous immunoglobulin

Toxic epidermal necrolysis (TEN) is a rare severe reaction of the skin resulting in full thickness damage to the epidermis. The condition has significant morbidity as a result of dehydration, protein loss, thermoregulatory difficulties, and renal, lung, liver and heart failure. The mortality rate approaches 30%, most commonly from bacterial sepsis. Management of this condition is cessation of the suspected causative agent and supportive care on a burns or intensive care unit. There have been recent reports of treatment using intravenous immunoglobulin (IVIG) therapy, though its efficacy is yet to be established. It has been proposed that IVIG inhibits the Fas-FasL mediated apoptosis of keratinocytes affected by TEN. We describe a case of extensive drug-induced TEN in a 33-year-old woman who showed rapid improvement with IVIG therapy at a dose of 0.75 g/kg/day given for four consecutive days.

A new once-daily formulation of tolterodine provides superior efficacy and is well tolerated in women with overactive bladder

This study evaluated the efficacy and tolerability of new extended-release (ER) tolterodine for the treatment of overactive bladder in women. In this subpopulation analysis of a double-blind multicenter trial, 1235 female patients were randomized to oral therapy with tolterodine ER 4 mg once daily (n=417), tolterodine IR 2 mg twice daily (n=408) or placebo (n=410) for 12 weeks. Both formulations reduced the mean number of urge incontinence episodes per week (both P=0.001 vs placebo); tolterodine ER was more effective than tolterodine IR (P=0.036). Both formulations significantly improved all other micturition chart variables compared to placebo. Dry mouth was the most common adverse event. There were no safety concerns. Toltrodine ER 4 mg once daily is effective and well tolerated in the treatment of women with overactive bladder, and reduces urge incontinence episodes more than the existing IR twice-daily formulation.

Quorum sensing as a population-density-dependent determinant of bacterial physiology

The discovery that bacterial cells can communicate with each other has led to the realization that bacteria are capable of exhibiting much more complex patterns of co-operative behaviour than would be expected for simple unicellular microorganisms. Now generically termed 'quorum sensing', bacterial cell-to-cell communication enables a bacterial population to mount a unified response that is advantageous to its survival by improving access to complex nutrients or environmental niches, collective defence against other competitive microorganisms or eukaryotic host defence mechanisms and optimization of population survival by differentiation into morphological forms better adapted to combating environmental threats. The principle of quorum sensing encompasses the production and release of signal molecules by bacterial cells within a population. Such molecules are released into the environment and, as cell numbers increase, so does the extracellular level of signal molecule, until the bacteria sense that a threshold has been reached and gene activation, or in some cases depression or repression, occurs via the activity of sensor-regulator systems. In this review, we will describe the biochemistry and molecular biology of a number of well-characterized N-acylhomoserine lactone quorum sensing systems to illustrate how bacteria employ cell-to-cell signalling to adjust their physiology in accordance with the prevailing high-population-density environment.

SdiA of Salmonella enterica is a LuxR homolog that detects mixed microbial communities

Proteins of the LuxR family detect the presence of N-acylhomoserine lactones (AHLs) and regulate transcription accordingly. When AHLs are synthesized by the same species that detects them, the system allows a bacterium to measure the population density of its own species, a phenomenon known as quorum sensing. The sdiA genes of Escherichia coli and Salmonella enterica serovar Typhimurium are predicted to encode LuxR homologs. However, these species do not appear to synthesize AHLs or any other molecule detected by SdiA. It has previously been demonstrated that overexpression of sdiA results in the activation of the ftsQAZ locus in E. coli and four other loci in Salmonella serovar Typhimurium. Here we report that transcriptional fusions to these five loci fall into two classes. The first class requires overexpression of sdiA for activation. The second class responds to sdiA expressed from its natural position in the chromosome if the appropriate AHLs are added to the culture. The only member of the second class is a series of Prck-luxCDABE fusions in Salmonella serovar Typhimurium. SdiA responds with highest sensitivity to AHLs that have a keto modification at the third carbon and an acyl chain length of 6 or 8 (half-maximal response between 1 and 5 nM). Growth of Salmonella in proximity to species known to synthesize these AHLs results in sdiA-dependent activation of the Prck-luxCDABE fusions. SdiA appears to be the first AHL receptor discovered that detects signals emanating exclusively from other species.

Mutation in Brca2 stimulates error-prone homology-directed repair of DNA double-strand breaks occurring between repeated sequences

Mutation of BRCA2 causes familial early onset breast and ovarian cancer. BRCA2 has been suggested to be important for the maintenance of genome integrity and to have a role in DNA repair by homology- directed double-strand break (DSB) repair. By studying the repair of a specific induced chromosomal DSB we show that loss of Brca2 leads to a substantial increase in error-prone repair by homology-directed single-strand annealing and a reduction in DSB repair by conservative gene conversion. These data demonstrate that loss of Brca2 causes misrepair of chromosomal DSBs occurring between repeated sequences by stimulating use of an error-prone homologous recombination pathway. Furthermore, loss of Brca2 causes a large increase in genome-wide error-prone repair of both spontaneous DNA damage and mitomycin C-induced DNA cross-links at the expense of error-free repair by sister chromatid recombination. This provides insight into the mechanisms that induce genome instability in tumour cells lacking BRCA2.